PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Child: GA
Place ID label here
A. Special Needs / Requirements
Language / Communication / Other Needs
Is an Interpreter Service required? Yes
No
Occupation
If Yes, is a qualified Interpreter present? Yes
No
B. Condition and procedure
This condition requires the following procedure.
Clinician to explain and document. Include site and/or side, all x-rays/investigations relevant to the procedure.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________
C. Risks of the procedure
There are risks / complications with this procedure.
They are listed on Page 3 and include but are not limited to this list.
Clinician to cross out and initial any statements on the consent risk list which are not relevant to the patient’s procedure
Serious or frequently occurring specific risks
There are risks / complications which are specific to this type of surgery / procedure.
They include but are not limited to the following Clinician to explain and document.
________________________________________________________________________________
________________________________________________________________________________
__________________________
D. Significant risks and procedure options
Clinician to explain and document in space provided. Continue on Page 3 if necessary.
________________________________________________________________________________
________________________________________________________________________________
__________________________
E. Risks of not having this procedure
Clinician to explain and document in space provided. Continue on Page 3 if necessary.
________________________________________________________________________________
________________________________________________________________________________
__________________________
F. Anaesthetic / Sedation
This procedure will require an anaesthetic and/or sedation.
Clinician to explain and document type of anaesthetic / sedation discussed. Continue on Page 3 if necessary.
________________________________________________________________________________
________________________________________________________________________________
__________________________
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To be retained in patient’s Healthcare Record
PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Child: GA
G. Patient Consent
I/we acknowledge that the clinician has explained my/my child’s medical/dental condition and proposed procedure.
I/we understand the risks, including those specific to me/my child.
Place ID label here
the anaesthetic required for this procedure.
I/we understand the risks, including those specific to me/my child.
my/my child’s prognosis and the risks of not having the procedure.
that no guarantee has been given that the procedure will improve
my/my child’s condition even though it has been carried out with due professional care.
other relevant procedure / treatment options and their associated risks.
that teeth, tissues and blood may be removed and could be used for diagnosis or management of my/my
child’s condition, or for education purposes, and will be stored and disposed of sensitively by the hospital.
that a person other than the Consultant may conduct the procedure.
I/we understand this could be a doctor/dentist/student undergoing further training.
I/we have been given the following Patient Information Sheet(s):
Your Anaesthetic
Your Sedation
About Your Procedure
I/my child was able to ask questions and raise concerns with the clinician about my/my child’s condition, the
proposed procedure and its risks, and my/my child’s treatment options. My/our questions and concerns have
been discussed and answered to my/our satisfaction.
I/we understand I/we have the right to change my/our mind at any time, including after I/we have signed this
form but preferably following a discussion with the clinician.
I/we also consent to such further or alternative operative measures as may be found necessary during the
course of the operation/procedure/treatment.
I/we understand that in the event of an inoculation injury to staff / students my child may be asked to give blood
for testing.
On the basis of the above statements -
I/we request to have the procedure
________________________________________________________________________________
Name of Parent/Substitute Decision Maker: ____________________ Signature: ________________
Relationship to Child: _____________________________________________Date: _____________
Legal authority If applicable: Source of decision-making authority (tick one)
Court Order
Court Order verified
Legal Guardian
Documentation verified
Other __________________________
Documentation verified
Optional Declaration for the Young Person
Based on a minor being capable of giving informed consent when he or she achieves a sufficient understanding
and intelligence to enable him or her to fully understand the nature, consequences and risks of the proposed
operation/procedure/treatment and the consequences of non-treatment.
I request to have the procedure
________________________________________________________________________________
Name: _____________________________Signature: ____________________ Date: ____________
H. Clinician Statement
I have explained to the patient / substitute decision maker all the above points under the Patient Consent Section G
and I am of the opinion that the patient / substitute decision maker has understood the information.
Name of Clinician: _________________________ Medical/Dental Council Reg. No: _____________
Signature: ____________________________________ Date: ______________________________
Interpreter Statement
I have interpreted the information given above by the clinician, to the patient / substitute decision maker, to the best
of my ability and in a way which I believe s/he can understand.
Name of Interpreter: _____________________ Signature: __________________ Date: __________
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To be retained in patient’s Healthcare Record
PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Child: GA
C. Risks of the procedure (Continued from Page 1)
There are risks and complications with this procedure.
They include, but are not limited to the following.
Clinician to cross out and initial any statements on this consent which
are not relevant to this patient’s procedure.
Place ID label here
General Risks: Anaesthetic
 Small areas of the lung can collapse, increasing the risk of chest infection or aspiration pneumonia.
This may require treatment, e.g. antibiotics / physiotherapy.
 Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
 Heart attack or stroke is possible owing to the strain on the heart and pre-existing known or unknown disease.
 Death or brain damage as a result of this procedure is very rare but possible.
Common Risks and Complications: Anaesthetic
 Minor pain, bruising and/or infection at the site of the IV cannula. This may require treatment with
antibiotics/painkillers.
 Pain, nausea/vomiting or discomfort, which may require medication; (e.g. airway injury, sore throat, nose bleeds,
muscle pains, eye injury, broken teeth, cut lips).
Less Common Risks and Complications: Anaesthetic
 Allergy to injected drugs, requiring further treatment. This can, in rare circumstances, be life-threatening or fatal.
 The procedure may not be possible owing to medical and/or technical reasons.
 Equipment faults may lead to injury.
Rare Risks and Complications: Anaesthetic
 Significant injuries i.e. seizures, brain damage, paralysis, neck injury, awareness, confusion and/or cardiac arrest.
 Damage to skin or kidneys
 Death as a result of this procedure is very rare (1 in 200,000 to 1 in 400,000 cases).
Less Common Risks and Complications: Procedure
 Infection, requiring antibiotics and further treatment.
 Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been
taking blood-thinning drugs.
 Damage to surrounding structures such as blood vessels, nerves, organs and muscles, requiring further treatment.
 Blood clot in the leg (DVT) causing pain and swelling. Rarely, part of the clot may break off and go to the lungs.
If Sedation is given Risks include:
 Faintness or dizziness, especially when you start to move around.
 Fall in blood pressure
 Nausea and vomiting
 Weakness
 An existing medical condition getting worse
 Heart and lung problems such as heart attack or vomit in the lungs causing pneumonia. This may require
emergency treatment
 Stroke resulting in brain damage.
Risks of Radiation:
The amount of medical radiation used in dental x-rays is so low that the risk of any damage to the body is minimal.
Further Discussion of Risks:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name of Anaesthetist: ____________________________ Medical Council Reg. No: _____________
Signature: ____________________________________ Date: ______________________________
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To be retained in patient’s Healthcare Record
PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT
Child: GA
I. Patient consent for image taking
(Photographs, radiographs, video / digital recordings)
I/we acknowledge that the clinician has explained that these images will be stored securely.
Place ID label here
help in the assessment of my/my child’s clinical dental problems
and in planning my/my child’s treatment.
will usually be requested when I/we attend for assessment and
at various stages during my/my child’s treatment.
also allow the clinician to follow the progress of my/my child’s clinical condition and any changes occurring
during and after treatment.
may be used anonymously for teaching, research and publication purposes.
Condition and procedure
Your/your child’s condition/procedure/course of treatment requires the following images of your/your child’s teeth/mouth/face.
Clinician to explain and document in space provided all photographs/x-rays where relevant and complete the additional
Imaging Log on separate sheet each time new images are taken.
________________________________________________________________________________
________________________________________________________________________________
____been given the following Patient Information Sheet(s):
I have
About My Images
I/my child was able to ask questions and raise concerns with the clinician about my/my child’s images. My/my
child’s questions and concerns have been discussed and answered to my/my child’s satisfaction.
I/we understand I/we have the right to change my/our mind at any time, including after I have signed this form
but preferably following a discussion with the clinician.
I/we understand that image(s) or video footage may be recorded as part of and during my/my child’s procedure
and that these image(s) or video(s) will assist the clinician to provide appropriate treatment.
I/we understand that images may be taken as part of and during my/my child’s procedure and that these
images may be used for the purpose of Teaching
Research
Publication
(Tick each box as appropriate)
On the basis of the above statements -
I/we request to have the following imaging ____________________________________________
Name of Parent/Substitute Decision Maker: ____________________ Signature: ________________
Relationship to Child: _____________________________________________Date: _____________
Legal authority If applicable: Source of decision-making authority (tick one)
Court Order
Court Order verified
Legal Guardian
Documentation verified
Other _____________________________
Documentation verified
Optional Declaration for the Young Person
Based on a minor being capable of giving informed consent when he or she achieves a sufficient understanding
and intelligence to enable him or her to fully understand the nature, consequences and risks of the proposed
operation/procedure/treatment and the consequences of non-treatment.
I request to have the following imaging _______________________________________________
Name: _____________________________Signature: ____________________ Date: ____________
Clinician Statement
I have explained to the patient / substitute decision maker all the above points under the Patient Consent Section I
for images and I am of the opinion that the patient / substitute decision maker has understood the information.
Name of Clinician: _________________________ Medical/Dental Council Reg. No: _____________
Signature: __________________________________________ Date: ________________________
Interpreter Statement
I have interpreted the information given above by the clinician, to the patient / substitute decision maker, to the best
of my ability and in a way which I believe s/he can understand.
Name of Interpreter: ____________________ Signature: _________________ Date: ____________
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To be retained in patient’s Healthcare Record