Informed Consent Documentation
What Should a Dental Consent Form Document?
A dental informed consent record generally documents who was involved in the discussion, what treatment was proposed, the benefits, the material risks, the reasonable alternatives including no treatment, the costs, and the patient's agreement. The checklist below is the framework ChartPilot consent forms are built around.
Informed Consent Documentation Checklist
Elements commonly expected in a dental informed consent record. Educational framework, not legal advice, and not a substitute for the requirements that apply in your jurisdiction.
- Patient name and date of discussion documented
- Provider name and discussion leader recorded
- Other participants in discussion noted
- Patient capacity to consent assessed (Y/N)
- Substitute decision-maker identified where applicable
- Nature and purpose of treatment explained
- Expected benefits reviewed
- Material risks and side effects disclosed and initialled
- Reasonable alternatives discussed including no treatment
- Consequences of not proceeding documented
- Educational materials offered
- Patient questions recorded
- Anticipated costs and lab fees disclosed
- Fee agreement and insurance responsibility confirmed
- Patient or SDM signature with date
"Most dental regulatory colleges do not provide pre-approved consent forms. ChartPilot forms were independently written against published professional informed consent principles. Review by a legal or regulatory professional is recommended before clinical use."
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