1. Purpose
This policy sets out how the Practice obtains, records and reviews valid consent for dental assessment and treatment.
It applies to NHS and private dental care, including consent recorded on NHS forms such as FP17DC where applicable, and separate private treatment-plan consent.
2. Sources to verify before adoption
- GDC Standards for the Dental Team, Principle 3, obtain valid consent: https://standards.gdc-uk.org/pages/principle3/principle3.aspx
- GDC Standards for the Dental Team, Principle 4, maintain and protect patients' information: https://standards.gdc-uk.org/pages/principle4/principle4
- CQC dental mythbuster 23, consent to dental treatment: https://www.cqc.org.uk/guidance-providers/dentists/dental-mythbuster-23-consent-dental-treatment
- Mental Capacity Act 2005: https://www.legislation.gov.uk/ukpga/2005/9/contents
- NHS consent to treatment, children and young people: https://www.nhs.uk/tests-and-treatments/consent-to-treatment/children/
3. Scope
This policy applies to:
- examinations
- treatment planning
- preventive, restorative, periodontal, surgical, orthodontic and cosmetic dental care
- dental radiography consent discussions where relevant
- treatment provided under NHS arrangements
- private treatment
- photography, video, study models and digital scans
- examination or treatment involving trainees or observers
4. Who can take consent
Consent is taken by a person who is competent to explain the proposed care and answer patient questions.
- Dentists take consent for treatment they prescribe or provide.
- Dental therapists and dental hygienists take consent for care within their scope of practice.
- Dental nurses and reception staff may support administrative parts of the process but do not replace the clinician's consent discussion.
- Where a trainee or observer is present, the supervising clinician ensures the patient understands who will be involved.
The Practice checks each role against current GDC scope and Standards guidance before assigning consent responsibilities.
5. What counts as informed consent
The clinician gives the patient information in a way the patient can understand. The discussion covers:
- diagnosis or reason for treatment
- treatment options
- expected benefits
- material risks
- likely consequences of not proceeding
- alternatives, including referral or no treatment where clinically appropriate
- likely number of visits
- cost and payment basis
- NHS or private status of the treatment
- any change to the treatment plan or cost after consent has been given
The clinician checks understanding and gives the patient the opportunity to ask questions.
6. Written, verbal and implied consent
Consent may be written, verbal or implied depending on the treatment and risk.
- Implied consent: may be suitable for low-risk routine examination steps, such as a patient opening their mouth after the clinician explains the examination.
- Verbal consent: may be suitable for routine treatment where the discussion and decision are recorded in the clinical notes.
- Written consent: is used for higher-risk, invasive, complex, cosmetic, sedation, implant, orthodontic or higher-cost treatment, and where the Practice's local procedure requires it.
A signed form records the discussion. It does not replace the discussion.
7. Capacity considerations
The Practice assumes an adult has capacity unless there is reason to assess otherwise.
Where capacity is in doubt, the clinician follows the Mental Capacity Act 2005 and records:
- the specific decision
- the information given
- the support offered to help the patient decide
- the capacity assessment outcome
- any best-interests decision
- who was consulted
- why the chosen option was the least restrictive practical option
The Practice does not treat a patient as lacking capacity because they make a decision staff disagree with.
8. Children and young people
The Practice follows current consent guidance for children and young people.
- Patients aged 16 or 17 are generally presumed able to consent to their own treatment unless there is evidence to the contrary.
- A patient under 16 may consent if the clinician assesses that they have enough understanding for the proposed treatment.
- Where the patient is not competent to consent, consent is sought from a person with parental responsibility.
- The clinician records the assessment, who gave consent and any disagreement that affected the decision.
The Practice verifies this section against current NHS and professional guidance before adoption.
9. Refusal and withdrawal of consent
Patients can refuse treatment or withdraw consent.
Where this happens, the clinician records:
- the treatment proposed
- the information given
- the patient's decision
- the risks explained
- any alternatives offered
- follow-up or safety-netting advice
If refusal creates an immediate safeguarding or capacity concern, staff follow the safeguarding policy and seek senior clinical advice.
10. Consent for photography, scans and trainees
The Practice obtains and records specific consent for:
- clinical photographs
- video or audio recording
- use of images for referral, laboratory, teaching, audit, website or marketing purposes
- examination or treatment by trainees
- observers in the surgery
The Practice records the purpose, where the image or recording will be stored, who may see it and whether it can be withdrawn.
11. Record-keeping
The clinical record includes enough detail to show the consent discussion took place. Records include:
- options discussed
- risks and benefits discussed
- cost information
- questions asked by the patient
- decision made
- consent form reference where used
- changes to treatment plan or cost
- capacity or child-competence assessment where relevant
- refusal or withdrawal of consent
Consent records form part of the patient record.
12. Audit
The Practice audits consent records at least annually, or more often where complaints, incidents or treatment type create higher risk.
The audit sample should include NHS care, private care, higher-risk procedures, radiography and any treatment involving written consent.
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.