Dental Examination, X-rays and Emergency Treatment Consent Form | Webform Portal

Consent to Dental Examination, X-rays and Emergency Treatment

Patient Name: *

Patient Email: *

Date of Birth: *

Having presented for a dental examination and investigation, I understand and consent to the examination of my head and neck, hard and soft tissues of the mouth, teeth and their supporting issues by way of clinical examination, any necessary scan or x-rays, impressions, and photographs. I further consent to any emergency treatment that may be required along with any referral to other members of the dental or medical team.

I have been informed of the risks and benefits involved, and all my questions have been answered to my satisfaction. Furthermore, I have been assured that any future questions I may have will also be answered by a member of the dental team.

By signing below, I agree that:
- I have read and understood the content of this form, or it was read to me.
- I have informed the dentist of any change in my medical and social histories.
- I confirm that I have been informed if my investigation/ treatment is to be conducted on an NHS or private basis or a combination of NHS and private.
- I was able to ask questions and they have been answered to my satisfaction.
- I was given the opportunity to have a support person/ an interpreter present.
- I choose to have this investigation and any emergency procedure/ operation/ treatment done and authorised the dentist to complete the plan with his/ her designated assistants to assist with the investigation/ treatment.
- I consent to any other emergency procedure if or as required to treat an unforeseen life-threatening event during my visit or treatment.
- I confirm that I have the ability to give my informed consent to the investigation/ treatment or I have the ability to give my informed consent to the investigation/ treatment if signing on behalf of the patient.

Patient's Signature: *

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I believe that the patient has fully understood the proposed investigation / treatment / procedure / operation.

Dentist's Signature: *

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