Patient consent form
Practice: Riverside Family Dental
Patient: Hannah Brooks
Date of birth: 4 July 1988
Patient number: P-20871
Clinician: Dr Sana Malik, dentist
Date: 7 November 2026
1. The treatment
Removal of the lower left wisdom tooth under local anaesthetic
Why it is recommended:
The tooth is decayed and has caused infection three times. Removing it should stop the pain and infection.
2. Benefits
Relief of pain and swelling
No more infection from this tooth
3. Risks and side effects
Pain and swelling for several days
Bleeding
Infection of the socket
Temporary or, rarely, lasting numbness of the lip or tongue
4. Other options
Treat the infection with antibiotics, which may return
Monitor the tooth
No treatment: the infection and pain are likely to come back
5. After the treatment
Do not rinse for 24 hours. Call 020 7946 0000 if bleeding or pain gets worse, or in an emergency, call the emergency number.
Cost: GBP 180
6. Your rights
- You can ask any question, and take time to decide.
- You can say no, or change your mind at any time before or during the treatment, by telling the clinician or any member of the team. Withdrawing consent will not stop you getting care.
- You can ask for a second opinion.
- Your health information is kept private and shared only as the law allows.
Language help: Telephone interpreter, Arabic
7. Who explained this, and the ability to decide
Explained by: Dr Sana Malik, dentist, in person on the day of the visit
Ability to decide: The patient understood the information and was able to decide for themselves.
Representative, if any: Not applicable
8. Consent
I confirm that:
- the treatment, its benefits, risks and other options, including having no treatment, were explained to me in a way I understand, in a language I understand;
- I had the chance to ask questions and my questions were answered;
- I agree to the treatment above, and I understand it may need to change if something unexpected happens, and the clinician will explain this where they can.
Consent given by: The patient
Name: ______________________ Relationship, if not the patient: ______________
Signature: ______________________ Date: ______________
Clinician: Dr Sana Malik, dentist
I have explained the above to the person signing. I believe they understood it and agreed freely. This form supports the conversation about the treatment and does not replace it.
Signature: ______________________ Date: ______________
Interpreter or helper, if one was used:
Name: ______________________ Signature: ______________________ Date: ______________