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    Dental Patient Consent Form: Please Be Sure To Ask Any Questions You Wish!

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    Cornelius Riki
    This dental patient consent form provides information about a recommended dental treatment. It explains that the dentist wants to ensure the patient understands the treatment and is comfortable proceeding. The form details the nature of the treatment, its benefits and prognosis, expected duration and costs, alternative treatments, and potential risks. It requires the patient's acknowledgment that they have received this information, understand the treatment options, and consent to the recommended treatment.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Dental Patient Consent Form: Please Be Sure To Ask Any Questions You Wish!

    Uploaded by

    Cornelius Riki
    66 views2 pages
    This dental patient consent form provides information about a recommended dental treatment. It explains that the dentist wants to ensure the patient understands the treatment and is comfortable proceeding. The form details the nature of the treatment, its benefits and prognosis, expected duration and costs, alternative treatments, and potential risks. It requires the patient's acknowledgment that they have received this information, understand the treatment options, and consent to the recommended treatment.

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    Informed concent

    Original Title

    Dental-Consent-Form

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    This dental patient consent form provides information about a recommended dental treatment. It explains that the dentist wants to ensure the patient understands the treatment and is comfortable proceeding. The form details the nature of the treatment, its benefits and prognosis, expected duration and costs, alternative treatments, and potential risks. It requires the patient's acknowledgment that they have received this information, understand the treatment options, and consent to the recommended treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    66 views2 pages

    Dental Patient Consent Form: Please Be Sure To Ask Any Questions You Wish!

    Uploaded by

    Cornelius Riki
    This dental patient consent form provides information about a recommended dental treatment. It explains that the dentist wants to ensure the patient understands the treatment and is comfortable proceeding. The form details the nature of the treatment, its benefits and prognosis, expected duration and costs, alternative treatments, and potential risks. It requires the patient's acknowledgment that they have received this information, understand the treatment options, and consent to the recommended treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    You are on page 1of 2

    DENTAL PATIENT CONSENT FORM

    This information is provided to help you understand the treatment I am recommending for you.
    Before I begin treatment, I want to be certain that I have provided you with enough information
    in a way you can understand, so that you’re well informed and confident that you wish to
    proceed. This form will provide some of the information. I will also have a discussion with you.

    PLEASE BE SURE TO ASK ANY QUESTIONS YOU WISH!

    It’s better to ask them now than wonder about it after we start the treatment.

    Nature of the Recommended Treatment:

    I am recommending the following treatment(s) for you:

    ____________________________________________________________________________

    I base this recommendation on the visual examination(s) I have performed, on any x-rays,
    models, photos and other diagnostic tests I have taken, and on my knowledge of your medical
    and dental history. I have also taken into consideration any information you have given me
    about your needs and wants. The treatment is necessary because:

    ____________________________________________________________________________

    The benefits of this treatment are:

    ____________________________________________________________________________

    The prognosis, or chance of success, of the treatment is:

    ____________________________________________________________________________

    I expect that it will take approximately ______________________to complete the treatment, but
    it could be shorter or longer based on what we experience as the treatment progresses.

    I expect it to cost about $ ______________ and I will let you know as soon as possible if the
    cost estimate increases or if it can be reduced.

    Alternative Treatments

    There are many ways to treat dental problems. I have chosen the one that I think best suits your
    needs. However, them are other ways that your condition can be treated, including:

    ____________________________________________________________________________

    If you have any questions about these alternatives, or about any other treatments you hove
    heard or thought about, please ask.

    Page 1 of 2
    Risks Of The Recommended Treatment

    No dental treatment is completely risk free. I will take reasonable steps to limit any
    complications of the treatment I have recommended. However, there are some complications
    that tend to occur with some regularity.

    These include:

    ____________________________________________________________________________

    If you have any questions about these complications, or about any other complications you have
    heard or thought about, please ask. I believe that the treatment will be most successful when
    you understand as much as possible about it, because you will be able to provide more
    information to me and to ask better questions. No question is too simple to ask and I have as
    much time to answer them as you need. When you feel you can make on educated decision
    about this recommendation, then we can get started with treatment.

    Acknowledgment

    I, _______________________, have received information about the proposed treatment.

    I have discussed my treatment with the undersigned Treating Dentist and have been given an
    opportunity to ask questions and have them fully answered. I understand the nature of the
    recommended treatment, alternate treatment options, and the risks of the recommended
    treatment and hold the Treating Dentist, and any of his/her associates, harmless of any
    wrongdoing in connection with the treatment. Provided that any complications did not arise due
    to negligence.

    Furthermore, I wish to proceed with the recommend treatment.

    Patient or Guardian

    Signature: ______________________________________ Date:________________________

    Treating Dentist

    Signature: ______________________________________ Date:________________________

    Witness

    Signature: ______________________________________ Date:________________________

    Page 2 of 2

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