What to Include on a Dental Treatment Consent Form

Your dental treatment consent form is a legal document, but it shouldn’t read like one.

When you create or update your dental treatment consent form, keep it simple. Your standard consent form can cover any number of procedures, but you can also easily adapt a simple form to include any specific treatments if you need to.

We’ve created a dental treatment consent form template for you to use with your clients. The sections and template here are purposefully general. For more specific procedures or a specialty practice, simply add in a paragraph or two that lays out the treatment and expectations for those oral health measures. These may include root canal therapy, tooth extraction, etc.

What to include on your dental treatment consent form

Patient information

Include basic patient information at the top of each dental treatment consent form. Some forms only include the patient’s name, but include any information that works best for your record keeping, such as contact information or insurance information.

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Since your patients will sign a general dental treatment consent form at the beginning of their first visit, the treatment plan needs to cover everything you expect from regular cleanings to fillings and x-rays.

Drugs and medications

Drugs and medications have side effects. Your consent form needs to make this clear without frightening your patient.

Changes in plan

A dental treatment plan can change mid-treatment depending on what you discover. Be sure your patient understands that any course of action may change as a result.


While general dentistry isn’t as risky as, say carrying the One Ring into the depths of Mordor, there are associated risks. Again, it’s not necessary to scare your patients. Just keep them aware of any risks associated with treatment.

Cost estimate

Inform your patients that the price you quote for treatment is an estimate that is subject to variation based on insurance or changes in the treatment plan.

Insurance and payment

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Include a statement about insurance and payment along with the cost estimate or as a separate section. Inform your patients that you will bill insurance on their behalf, but they are responsible for any charges and fees that insurance does not cover.


The patient should sign and date the consent form before you begin working with them. This is also a good moment to remind your patients that they are free to ask any questions, and they are free to withdraw consent at any time.

Initials for each section

If your dental treatment consent form is lengthy, include a line for patient initials after each section.

Here is a sample dental treatment consent form you can use or alter to fit the needs of your practice.

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Dental Treatment Consent 

Patient name: ___________________

Treatment: _____________________

I understand and consent to normal and necessary dental treatments to maintain good oral health. Treatments include, but are not limited to:

X-Rays, Cleanings, Fillings and Repairs, Crowns and Caps, Impressions, and Local Anesthesia, etc.

I understand my dentist will discuss any procedures with me and answer any questions I may have.

Drugs and medication

I understand any analgesic or anesthetic drugs may, in rare cases, have unexpected side effects, including allergic reactions, redness, swelling, pain, itching, and vomiting. I have disclosed all prescriptions and over-the-counter medications I am currently taking. I have informed my dentist of all known allergies.

Changes in treatment

I understand it may be necessary to change or add procedures during dental treatments due to unforeseen complications or dental conditions. I will be informed of any changes and given the opportunity to approve or deny any additional procedures.


General dentistry procedures do carry a minimal risk. Most often you will experience temporary pain, swelling, some bleeding, or minor discomfort from dental procedures. I am aware of the risks for the procedures I will need.


I understand that the quoted cost of my dental care is an estimate, and is subject to change for any reason. I understand that (your dental office) will bill my insurance company on my behalf. I further understand that I am responsible for any charges not covered by my insurance, including, but not limited to co-payments and deductibles.


I understand dentistry is not an exact science, and my care provider cannot ensure specific results. By signing, I agree that I have read and understand the course of my dental care.

Patient’s Signature________________________   Date _________

Witness’ Signature________________________    Date _________

What would you add to a dental treatment consent form? Let us know in the comments.

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