Dental Patient Consent Form

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The dental patient consent form is used for any type of oral surgery or treatment in order to hold the dentist harmless of any wrong-doing (unless there is evidence of malpractice). The surgery may be for any type of tooth repair/pulling/implant and whether the patient will be consciously sedated or put under anesthesia. The form should be signed by the patient before any medication or medical treatment is assigned for the operation.

Root Canal ONLY Consent Form (Adobe PDF, MS Word) – This is for the dentist to be able to provide services exclusively in relation to a needed root canal.

How to Write

Step 1 – Download in Adobe PDF (.pdf) or Microsoft Word (.docx).

Dental Patient Consent FormAdobe PDFMS Word


Step 2 – Enter the following information in the first portion of the form:

  • Patient name
  • Date of Birth
  • Name of dentist
  • Name of office
  • Tooth number

Check one of the available options to indicate the nature of the procedure.

Step 3 – The date and signature of each of the below individuals will be required before handing the form back to the reception of the dentist’s office.

  • Patient
  • Parent or legal guardian
  • Witness or interpreter
  • Dentist