Dental Treatment Consent

What is your gender?

Choose one:

• Female
• Male
• Non-binary
• Prefer not to say

In what year were you born?

A number from 1910 to 2026

How often do you do each of the following?

• Brush your teeth at least twice a day
• Clean between your teeth with floss or small brushes
• See a dentist for a check-up at least every six months
• Have sugary snacks or drinks

For each row: choose one:

• Never
• Rarely
• Sometimes
• Often
• Always

Which of these dental treatments have you had before? Select all that apply.

Choose any that apply:

• Root canal
• Implants
• Crowns
• Whitening
• Orthodontics
• Gum surgery
• None

Do any of these apply to you? Select all that apply.

Choose any that apply:

• Diabetes
• Heart condition
• High blood pressure
• Bleeding disorder
• Pregnancy
• None of these

Are you allergic to any medicines or dental materials, such as latex or local anaesthetic?

Choose one:

• Yes
• No
• Not sure

What are you allergic to, and what reaction do you have?

Condition: Shown when the patient has an allergy

Open answer

List any medicines you take regularly. (optional)

Open answer

Do you agree to the dental treatment your dentist has explained and recommended?

Choose one:

• Yes
• No

Please type your full name to sign this consent.

Condition: Shown when the patient consents

Open answer

What would you like to discuss with your dentist before deciding? (optional)

Condition: Shown when the patient does not consent

Open answer