✎ Consent Form — General Dental Procedure — A4, fillable. Corrections applied: address/medical history fields fixed, procedure list matches your actual services.

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NOVACHEM

DENTAL CLINIC

PATIENT ID

DATE

Informed Consent Form

General Dental Procedure Consent

1. PATIENT DETAILS

Patient Name

Age

Gender

Male Female

Contact Number

Email (optional)

Address

Medical History Reviewed

Yes No

If yes, attach / mention details

Allergies (if any)

Current Medications

2. TYPE OF DENTAL PROCEDURE

3. TREATMENT ADVICE

Treatment advised by doctor

4. PATIENT CONSENT

I, the undersigned, confirm that the doctor has fully explained to me the nature of the dental procedure, the benefits, possible risks and alternative treatment options, as well as the expected outcomes. I have been given the opportunity to ask questions and all my questions have been answered to my satisfaction. I voluntarily consent to the dental procedure mentioned above.

5. SIGNATURES

Patient / Guardian Signature

(sign after printing)

Dentist Signature

(sign after printing)

Witness Signature (if applicable)

(sign after printing)

FOR CLINIC USE — PATIENT COPY

اردو میں رضامندی کا بیان (Urdu Consent Statement)

ڈاکٹر نے مجھے میرے دانتوں کے علاج کے طریقہ کار، ممکنہ خطرات، فوائد اور متبادل علاج کے بارے میں مکمل طور پر بتایا ہے۔

تمام سوالات کے جوابات سے میں مطمئن ہوں اور اپنی مرضی سے اس علاج کے لیے رضامند ہوں۔

This document is a record of informed consent and does not replace professional legal advice. Retain a signed copy in the patient’s file.