Consent to dental operation

1.1 I [insert name of patient] hereby consent to undergo the operation/treatment of [insert details of operation or treatment] to be carried out under [insert type of anaesthesia].

OR

1.2 I [insert name] being the parent(s) or guardian(s) of [name of patient] hereby consent to the latter undergoing the operation/treatment [insert details of operation or treatment] to be carried out under [insert type of anaesthesia].

2. I confirm that the nature and procedures for the operation or treatment, as well as its indication have been fully explained to me by [insert name of dentist].

[Specify details]

3. Furthermore, I confirm that the risks of complications and side effects of the operation/treatment and the anaesthesia

[Please provide details]

has also been explained to me by [insert name of dentist], and I understand and accept the same.

Signature of Patient: ________________	Name: __________________________
Signature of Parent(s) /Guardian(s): ______________________	Name: __________________________
Signature of Dentist: ________________	Name: __________________________
Signature of Witness: _______________	Name: __________________________

Date: