Dental appointment request form
Patients request a check-up or treatment with their reason for visit, preferred day and time of day.
Dental treatment consent form
Informed consent starts with the conversation between dentist and patient. This template records the result in writing: which treatment was discussed and when, and three separate confirmations that the treatment and alternatives were explained, questions were answered and consent can be withdrawn. An optional field catches questions that are still open, so you can answer them before the appointment. It doesn't contain treatment risks or medical text; your own information sheet stays the basis.
Opens as an editable form in your dashboard. If you're not signed in yet, you'll sign in or create an account first.
This template is a starting point, not legal advice. Check the questions, the consent text and how long you keep the answers against the data protection rules that apply to your practice.
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What's in this template
Every field can be renamed, reordered, made optional or removed in the form builder.
- Full nameShort answer · Required
- Phone numberPhone · Optional
- Treatment discussedShort answer · Required
- Date of the conversationDate · Required
- ExplanationCheckbox · Required
- QuestionsCheckbox · Required
- WithdrawalCheckbox · Required
- Questions you'd still like answered (optional)Long answer · Optional
- ConsentCheckbox · Required
How to use this template
Open it in your dashboardSelect “Use this template”. If you don't have an account yet, sign up first; the form opens right after.
Make it yoursChange the questions, options, colours and the thank-you message in the form builder, then save.
Share it and get submissionsShare the form's link or link to it from your website. Each submission is emailed to you and saved in your dashboard.
Tips for this form
- Add the information sheet for the treatment as a link in a paragraph above the confirmations, so patients can read it again.
- Check whether your country or professional body requires a signed paper form for certain treatments, and keep using it where it does.
- Send the form after the conversation, not instead of it, and read open questions before the treatment day.
- Keep the three confirmations as separate checkboxes, so each one is a clear answer of its own.
Running a business like this? See how Zotview sets up the website, booking and forms for Clinics and practices.
Zotview for Clinics and practicesQuestions about this template
Does this form replace the explanation by the dentist?
No. Consent needs the conversation in person. The form only documents that it took place and what was discussed.
Why doesn't the template list treatment risks?
Risks depend on the treatment and on the patient, and they belong in your own information sheet and conversation. A general list in a template could be incomplete or wrong.
Is a form submission legally enough as consent?
That depends on your country and the treatment. The template is a starting point, not legal advice; ask your professional body or a lawyer which form of consent you need.
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Start with this form, change anything later
The template opens in the form builder, where you can edit every question and choose who receives the submissions.