Dental Procedure Informed Consent Form
Patient Information
Patient Name
Date of Birth
Address
Phone Number
Procedure Details
Procedure Name
Description of Procedure
Reason for Procedure
Alternatives to This Procedure
Risks, Complications, and Side Effects
Expected Benefits
Consent Confirmation
I have read and received an explanation of the procedure and its risks.
My questions have been answered to my satisfaction.
I voluntarily consent to the proposed dental procedure.
Signatures
Patient/Legal Guardian Signature
Date
Dentist Signature
Date