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