DENTAL CONSENT FORM

Dental Consent Form

Dental Consent Form

Patient Name: _________________________
Date of Birth: _________________________
Phone Number: _________________________
Address: ______________________________

Procedure Information

I, (Patient’s Name), acknowledge that my dentist, Dr. [Dentist’s Name], has explained the recommended dental procedure, including its risks, benefits, and alternatives. The procedure(s) to be performed include:

☐ Tooth Extraction
☐ Root Canal Therapy
☐ Dental Filling
☐ Crown/Bridge Placement
☐ Scaling and Root Planing
☐ Other: ___________________________

Possible Risks and Complications

I understand that, as with any medical procedure, dental treatments carry certain risks, including but not limited to:

• Pain, swelling, or discomfort

• Bleeding or infection

• Temporary or permanent numbness

• Jaw stiffness or difficulty opening the mouth

• Need for additional treatments if complications arise

Anesthesia and Pain Management

☐ Local Anesthesia (numbing injection)
☐ Nitrous Oxide (laughing gas)
☐ Oral Sedation (medication taken before the procedure)

I understand the type of anesthesia being used and any associated risks.

Post-Treatment Care

I acknowledge that I have been given post-treatment instructions and understand my role in following them for proper healing. I also understand the need for follow-up visits, if required.

Patient Consent

I have had the opportunity to ask questions regarding my treatment. I understand the information provided, and I voluntarily consent to the procedure(s).

Patient/Guardian Name (Print): ________________________
Signature: ________________________
Date: ________________________

Dentist Name (Print): ________________________
Signature: ________________________
Date: ________________________