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General Dental Treatment Consent Form Mobile App

This General Dental Treatment Consent Form app is commonly used by dental care offices to read and consent to various procedures. Details x-rays, medications, treatment changes, tooth removal, crowns and bridges, dentures, root canals, fillings and more. This app allows the client to initial each relevant field stating they understand the procedure and sign in the signature field at the end to consent to the proposed treatment.

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Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Dentist's Name

  • Ico textbox

    Patient's Name

  • Ico statictext

    Please read and initial the items checked below and read and sign at the bottom of form.

  • Ico checkbox

    1. X-RAYS

  • Ico textbox

    Initials

  • Ico checkbox

    DRUGS AND MEDICATIONS - I understand that antibiotics and analgesics and other medications can c...

  • Ico textbox

    Initials

  • Ico checkbox

    CHANGES IN TREATMENT PLAN - I understand that during treatment it may be necessary to change or ...

  • Ico textbox

    Initials

  • Ico checkbox

    REMOVAL OF TEETH - Alternatives to removal have been explained to me (root canal herapy, crowns,...

  • Ico textbox

    Initials

  • Ico checkbox

    CROWNS, BRIDGES AND CAPS - I understand that sometimes it is not possible to match the color of ...

  • Ico textbox

    Initials

  • Ico checkbox

    DENTURES, COMPLETE OR PARTIAL - I realize that full or partial dentures are artificial, construc...

  • Ico textbox

    Initials

  • Ico checkbox

    ENDODONTIC TREATMENT (ROOT CANAL) - I realize there is no guarantee that root canal treatment wi...

  • Ico textbox

    Initials

  • Ico checkbox

    PERIODONTAL LOSS (TISSUE & BONE) - I understand that care must be exercised in chewing on fillin...

  • Ico textbox

    Initials

  • Ico checkbox

    FILLINGS - I understand that care must be exercised in chewing on fillings especially during the...

  • Ico textbox

    Initials

  • Ico checkbox

    DENTURES - I understand the wearing of dentures is difficult.

  • Ico textbox

    Initials

  • Ico statictext

    I understand that dentistry is not an exact science and that, therefore, reputable practitioners ...

  • Ico signature

    Signature of Patient

  • Ico date

    Date

  • Ico signature

    Signature of Parent/Guardian (if patient is a minor)

  • Ico date

    Date

  • ...and More!

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