Consents & releases 2 signers 2 pages 13 blanks to fill in

Dental Treatment Consent Form

Root canal, extraction or implant: the patient sees the plan, the risks, the alternatives and the estimate, then signs.

Use this template — free See the agreement Signers don’t need an account
Dental treatment consent
The blanks in brackets are what you fill in. FileIt adds each signer’s signature and date boxes.
Dental treatment consent — page 1 of 2
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Dental treatment consent — page 2 of 2
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Use this template Fill in the blanks, name who signs, and send — from FileIt eSignature.

What is a dental treatment consent?

Good dental consent is specific. 'Treatment as discussed' tells a patient, or anyone looking back later, very little. This form puts the actual procedure, the reason for it, its particular risks and the other options in writing, alongside an honest cost estimate.

It names the practice, dentist and patient. It describes the planned procedure and why it's recommended, lists general risks with the ones specific to this treatment, and records the alternatives discussed, including no treatment. You choose the anaesthesia, and the form adds the right notes for local anaesthetic, sedation or a general anaesthetic. It sets out the number of visits, the cost estimate and what it includes, and says extra work needs the patient's agreement first. The patient confirms their health history, that they had time to ask questions, and that they can withdraw consent.

Best for
General dentists, oral surgeons, endodontists and implant clinics
Signed by
The patient and the dentist
Anaesthesia
Local, local with sedation, general, or none
Length
2 pages

When to use a dental treatment consent

  • Root canal treatment followed by a crown
  • Wisdom tooth extraction
  • Dental implants and bone grafts
  • Bridges, veneers and larger cosmetic plans
  • Treatment under conscious sedation

What you fill in

13 blanks, then the name and email of each person who signs: patient, dentist.

1 The practice

  • Practice name*
  • Dentist's name*

2 The patient

  • Patient's name*
  • Date of birth

3 The procedure

  • Planned procedure*
  • Why it is recommended*

4 Risks and alternatives

  • Specific risks of this procedure*
  • Alternatives discussed*

5 Anaesthesia

  • Anaesthesia* local anaesthetic · local anaesthetic with conscious sedation · general anaesthetic · no anaesthetic

6 Cost

  • Number of visits
  • Currency*
  • Cost estimate*
  • What the estimate includes (optional)

7 Who signs

  • Patient signature and date · The adult patient. For a child, a parent or guardian signs.
  • Dentist signature and date, job title

What the dental treatment consent covers

  1. The proposed treatment
  2. Risks
  3. Alternatives
  4. Anaesthesia
  5. Cost
  6. My health
  7. Questions and consent

Using the dental treatment consent, step by step

1 Practice and patient

Your practice name fills in from your account. Add the dentist and the patient's name and date of birth.

2 The procedure

Describe the treatment, including the tooth, and why you're recommending it. Then list the risks specific to this procedure and the alternatives you discussed.

3 Anaesthesia and cost

Choose the anaesthesia, add the number of visits, the estimate and a note on what it includes or whether insurance is confirmed.

4 Give time to decide

Send it after the consultation so the patient can read it at home. They sign online, you countersign, and the consent sits with their record in FileIt.

Tips before you send it

  • Write the risks for this patient and this tooth, not a generic list.
  • Always record 'no treatment' as an alternative, with what's likely to happen.
  • Use a separate sedation consent with fasting and escort instructions where you sedate.
  • Update the estimate in writing if the plan changes.

Sign it online in minutes

  1. Fill in the blanks. Names, dates and amounts go straight into the agreement — the preview shows exactly where.
  2. Name who signs. Tick “This is me” for your own part. FileIt builds the PDF with every signature, date box on the right line, and you can check or move anything before sending.
  3. Send it. Each signer gets a secure link and signs from any device — no account needed. The signed PDF, with an audit trail and a Certificate of Completion, is filed in your vault and emailed to everyone.
Use the dental treatment consent template — it’s free

Dental treatment consent: frequently asked questions

Is the cost binding?

It's an estimate. If more work turns out to be needed, the dentist explains the change and the cost and asks first, unless stopping would put the patient's health at risk.

Can a parent sign for a child?

Yes. The form is written for the patient, and for a child a parent or guardian signs as the patient's representative.

Does it cover sedation in full?

It notes the key points for sedation and general anaesthesia, and says those are explained and agreed separately with their own instructions.

Can the patient change their mind?

Yes, before or during treatment. The dentist explains what stopping would mean at that stage.

Use this template — free