# Patient Consent Form Template, Free Source: https://nerix.ai/templates/patient-consent-form Record that a patient was told about a treatment, its risks and options, and agreed freely. Before you send it This is a template, not legal or medical advice. The rules on consent, who may give it (children, people who cannot decide for themselves) and what must be explained differ by country and by treatment. Consent is a conversation, not just a signature: have a qualified person explain and check your local requirements. ## Fill it in and preview You are signed in. Fill it in your workspace and it is kept as a document you can send, share and have signed. [Open in your workspace](https://app.nerix.ai/documents/templates/patient-consent-form) ### 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: ______________ Templates are a careful starting point, not legal advice. Where the law matters, check what applies where you are. Operations and quality ## What this template is for A patient consent form for a treatment or procedure: what it is, benefits, risks, choices, the right to say no, and signatures. Fill it in online. It is free to fill in online, needs no account, and downloads as a Word document or a PDF. [See all Operations and quality templates](https://nerix.ai/templates/operations-quality) Operations and quality ## What you fill in The form asks for 17 details. The document fills itself in as you type. - ### Practice or clinic For example: Riverside Family Dental - ### Patient's name For example: Hannah Brooks - ### Date of birth For example: 4 July 1988 - ### Patient number (optional) optional For example: P-20871 - ### Clinician giving the treatment For example: Dr Sana Malik, dentist - ### Treatment or procedure For example: Removal of the lower left wisdom tooth under local anaesthetic - ### Why it is recommended For example: The tooth is decayed and has caused infection three times. Removing it should stop the pain and infection. - ### Expected benefits For example: Relief of pain and swelling No more infection from this tooth - ### Possible risks and side effects Common ones and serious ones, in plain words. One per line. For example: Pain and swelling for several days Bleeding Infection of the socket Temporary or, rarely, lasting numbness of the lip or tongue - ### Other options, including doing nothing For example: Treat the infection with antibiotics, which may return Monitor the tooth No treatment: the infection and pain are likely to come back - ### Aftercare and who to call (optional) optional For example: 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, if any (optional) optional For example: GBP 180 - ### Interpreter or helper (optional) optional For example: Telephone interpreter, Arabic - ### Who explained this to the patient Name, role and how it was explained. For example: Dr Sana Malik, dentist, in person on the day of the visit - ### Ability to decide Be honest. If you are unsure, take advice before treating. For example: The patient understood the information and was able to decide for themselves. - ### Representative's name and relationship (optional) optional Only if someone else is consenting: name and why they may decide (parent, guardian, other). For example: Not applicable - ### Who is giving consent For example: The patient Operations and quality ## What is inside The parts of this document, in order. - 1 1. The treatment - 2 2. Benefits - 3 3. Risks and side effects - 4 4. Other options - 5 5. After the treatment - 6 6. Your rights - 7 7. Who explained this, and the ability to decide - 8 8. Consent Templates ## How it works - 01 ### Fill in Type your details in the form. The document fills itself in as you type; click any gap to jump to its field. - 02 ### Check Read it through. Gaps you have not filled stay marked, so nothing goes out half done. - 03 ### Download Save it as a Word document to edit further, or as a PDF to send or print. ### Make it yours with AI Open it in the chat and ask for changes: shorter, firmer, another situation, another language. [Adapt it with nerix](https://nerix.ai/try?template=patient-consent-form) ### Was this template helpful? Operations and quality ## Questions people ask ### What details does this template ask for? The form asks for 17 details, starting with Practice or clinic, Patient's name, Date of birth, Clinician giving the treatment, Treatment or procedure. 5 more are optional. ### Can I download this template as Word or PDF? Yes. When you have filled in the form, save it as a Word document to keep editing, or as a PDF to send or print. It is free and needs no account. ### Is what I type sent anywhere? No. What you type stays in your browser while you fill in the document. It only goes to nerix if you choose to open the template in the chat. ### What should I check before I use this template? This is a template, not legal or medical advice. The rules on consent, who may give it (children, people who cannot decide for themselves) and what must be explained differ by country and by treatment. Consent is a conversation, not just a signature: have a qualified person explain and check your local requirements. ### Are these operations templates free? Most are. Fill in and download them for free as Word or PDF, with no account. A few longer documents are premium: free to fill in, paid once to download, and marked with their price. ### Do they meet a standard such as ISO 9001? They are a practical starting point and certify nothing. Standards and safety laws differ by industry and country, so check what applies to you. ### Who should approve a procedure? The person who owns the process and a manager who can authorise it. The procedure template has fields for both, and for the review date. Templates ## More in Operations and quality - [Allergen and food safety record One page for the kitchen: allergens by dish, daily temperature and cleaning checks, and what was done about problems. Operations and quality](https://nerix.ai/templates/allergen-and-food-safety-record) - [Asset handover and return form Record equipment given to a person and returned later, with condition and signatures. Operations and quality](https://nerix.ai/templates/asset-handover-and-return-form) - [Asset register List what the business owns: each asset, who has it, where it is, what it is worth and its condition. Operations and quality](https://nerix.ai/templates/asset-register) - [Business continuity plan Plan how to keep critical work going through a fire, outage, supplier failure or loss of people. Operations and quality Premium, €4.99](https://nerix.ai/templates/business-continuity-plan) - [Capacity plan Work out whether you can meet future demand: current use, expected growth, gaps, options and what to decide. Operations and quality](https://nerix.ai/templates/capacity-plan) - [Class register Record attendance for one class or session, with late and absent names and the reason. Operations and quality](https://nerix.ai/templates/class-register) [See all Operations and quality templates](https://nerix.ai/templates/operations-quality) Templates ## More kinds of documents Every category has its own page, so you can see all of its templates at once. ## Use it in nerix ### Use it in nerix - [Templates](https://nerix.ai/product/templates) - [Quality records](https://nerix.ai/product/quality-records) - [Checks](https://nerix.ai/product/audits) ### Learn more - [How to Make a Document From a Template](https://nerix.ai/help/make-a-document-from-a-template) - [Operations and quality](https://nerix.ai/templates/operations-quality)