Informed Consent Form

Scaling (Dental Cleaning)

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. PROCEDURE

Treatment / Procedure

Scaling (Dental Cleaning)

Tooth / Teeth Involved

Brief Explanation

Scaling is a non-surgical procedure to remove plaque, tartar (calculus) and stains from the teeth, especially above and below the gumline, to improve oral hygiene and gum health.

3. BENEFITS

Removes plaque and tartar from teeth.
Helps prevent gum disease and tooth decay.
Helps reduce bad breath.
Helps maintain healthy gums and supporting tissues.
Improves overall oral health and appearance.

4. RISKS & COMPLICATIONS

Mild to moderate discomfort during or after the procedure.
Sensitivity of teeth (temporary).
Gum soreness or slight bleeding (usually resolves within 1–2 days).
Rare risk of infection.
Very rare risk of root surface damage.
Existing dental conditions may require additional treatment.

5. ALTERNATIVES

Alternative Treatment Options: Fluoride treatment, improved oral hygiene practices, use of desensitizing toothpaste.

Option of No Treatment: Plaque and tartar will continue to build up, which may lead to gum disease, bad breath, tooth decay and other oral health problems.

Consequences of Delaying / Refusing Treatment: Progression of gum disease (gingivitis/periodontitis), tooth decay, bone loss and possible tooth loss.

6. PATIENT ACKNOWLEDGEMENT

I have been informed about the nature of the procedure, its benefits, risks, possible complications, alternatives and the consequences of not having the treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

7. CONSENT

I voluntarily consent to undergo the above-mentioned procedure.

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.