Sample policy · Dental

Consent for treatment policy (dental)

Statutory anchor: Regulation 11 (need for consent), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The consent of children and young people is governed primarily by the common law (Gillick competence) and by the Mental Capacity Act 2005 where an adult lacks capacity; the standard for what information must be disclosed is set by the Montgomery v Lanarkshire Health Board principles. Professional consent duties for dental teams are set by the GDC Standards for the Dental Team, Principle 3. · primary source

1. What the regulation says

Care and treatment of service users must only be provided with the consent of the relevant person. (Reg 11(1): the headline duty)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/11. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You can only provide care or treatment with the consent of the relevant person. If the service user is 16 or over and lacks capacity, follow the Mental Capacity Act 2005. If Parts 4 or 4A of the Mental Health Act 1983 apply, follow that instead. Section 5 of the MCA (acts done in connection with care or treatment) still applies underneath.

3. 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.

4. Sources to verify before adoption

5. Scope

This policy applies to:

6. Who can take consent

Consent is taken by a person who is competent to explain the proposed care and answer patient questions.

The Practice checks each role against current GDC scope and Standards guidance before assigning consent responsibilities.

7. What counts as informed consent

The clinician gives the patient information in a way the patient can understand. The discussion covers:

The clinician checks understanding and gives the patient the opportunity to ask questions.

8. Written, verbal and implied consent

Consent may be written, verbal or implied depending on the treatment and risk.

A signed form records the discussion. It does not replace the discussion.

9. 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 Practice does not treat a patient as lacking capacity because they make a decision staff disagree with.

The Mental Capacity Act 2005 and Regulation 11 consent requirements are unchanged by the Supreme Court's 2026 AGNI judgment on deprivation of liberty. The Practice does not apply the AGNI "valid consent to confinement" analysis to capacity assessment or consent to dental treatment.

10. Children and young people

The Practice follows current consent guidance for children and young people.

The Practice verifies this section against current NHS and professional guidance before adoption.

11. Refusal and withdrawal of consent

Patients can refuse treatment or withdraw consent.

Where this happens, the clinician records:

If refusal creates an immediate safeguarding or capacity concern, staff follow the safeguarding policy and seek senior clinical advice.

12. Consent for photography, scans and trainees

The Practice obtains and records specific consent for:

The Practice records the purpose, where the image or recording will be stored, who may see it and whether it can be withdrawn.

13. Record-keeping

The clinical record includes enough detail to show the consent discussion took place. Records include:

Consent records form part of the patient record.

Operational controls to adapt

Roles and responsibilities

Step-by-step consent procedure

  1. Confirm the decision being made. Record the proposed examination, investigation, treatment plan, radiograph, photograph, scan or referral.
  2. Explain options and costs. Discuss NHS and private status, treatment options, no-treatment option, expected benefits, material risks, number of visits and likely costs.
  3. Check understanding. Give the patient time to ask questions, use accessible information or interpreter support where needed, and record the patient's questions.
  4. Check capacity or child competence. Use the Mental Capacity Act, Gillick competence or parental-responsibility route where relevant, and record the decision-specific assessment.
  5. Record consent before treatment starts. Use written consent where required by the treatment type or local procedure, but keep the clinical note as the evidence of the discussion.
  6. Reconfirm if the plan changes. New risks, costs, procedures, providers, materials, sedation, referral routes or delays require the consent discussion to be updated.
  7. Respect refusal or withdrawal. Record what was refused, the risks explained, alternatives offered, safety-netting advice and any safeguarding or capacity concern.
  8. Escalate failures. Missing consent, alleged pressure, unexpected treatment, cost disputes, capacity concerns or consent complaints are opened on the relevant register.

Records and evidence fields

The dental consent record should include:

Training and competence

Each role must understand what it can and cannot explain. Clinicians keep evidence of consent, capacity, child-consent and material-risk training. Support staff receive training on administrative explanations, escalation and avoiding clinical advice beyond their role.

Links to registers and action tracking

Consent complaints, cost disputes, missing records, alleged pressure, wrong treatment, capacity uncertainty and repeated documentation gaps are logged on the complaint, incident, safeguarding, risk or improvement-actions register as appropriate.

14. 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.

15. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

Related reading

16. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

17. Document control

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, consent procedure, evidence fields, training controls, register links and related reading.
v0.1 2026-05-21 Verivius (sample) Initial dental consent template.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: statutory anchor, verbatim Regulation 11 quote, plain-English summary, sources and further reading, and document control added; existing operational sections preserved and renumbered.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Dental consent carries something most regulated care does not: the clinical decision and the money decision are taken in the same conversation, often in the chair, minutes before an irreversible procedure begins. A patient who agreed to a filling and left with a root canal and a crown, or who believed the work was NHS and received a private bill, has not had a poor administrative experience: they have had treatment they did not agree to. The consent trail is what lets the treating clinician, the colleague who picks the patient up at the next visit and the patient themselves see what was genuinely discussed, including the options offered, the material risks, what happens if nothing is done and what changed after the plan was first agreed. Because children and young people make up so much of a dental list, the record also has to show whether the young person was assessed as able to decide for themselves rather than the practice defaulting to the adult who brought them. Notes of that quality are what turn a signature into an informed decision.

  1. The consent discussion is evidenced in the clinical note, not a signed form standing in for a conversation that may not have taken place.

    Strong evidence: The clinical record fields showing options discussed, risks and benefits, cost information, patient questions and the decision made, with the policy stating a signed form records the discussion but does not replace it.

    Weak evidence: A signed form carrying the patient's name and a tick against "risks explained", sitting alongside a clinical note that says only "consent obtained" or "C/O" with nothing about which options were offered, what the material risks were, what happens if nothing is done, or what the patient asked. The same sentence appearing word for word across many patients, or a note written up after the appointment with nothing to show the discussion happened before treatment started.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(1) and reg 17(2)(c)

  2. Consent is reconfirmed when the plan, materials, sedation, referral route or cost changes, not carried over from the first discussion.

    Strong evidence: The record of treatment-plan or cost changes and the confirmation that consent remained valid at the start of treatment (procedure step 'Reconfirm if the plan changes').

    Weak evidence: Consent recorded once at the treatment-planning visit and never revisited, so the record shows a composite agreed at one appointment and a crown fitted at the next with no entry in between. A changed material, an added extraction, sedation introduced or a switch from NHS to private care where only the estimate on the practice-management system was updated, with no clinical entry confirming the patient was told and agreed before treatment started.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. Where capacity is in doubt, a decision-specific assessment is recorded under the Mental Capacity Act 2005, not incapacity assumed from a choice staff disagreed with.

    Strong evidence: The capacity record (the specific decision, information given, support offered, assessment outcome, best-interests decision, who was consulted and why the chosen option was the least restrictive), with the policy barring treating a patient as lacking capacity because they decide against advice.

    Weak evidence: An entry reading "patient lacks capacity" or "capacity assessed, no concerns" with no record of which specific decision was being made, what information was given, what support was offered to help the patient decide, or the best-interests reasoning and who was consulted. Or an assessment that appears in the notes only after the patient declined the recommended treatment, so the disagreement is doing the work an assessment should have done.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 ss.1(4), 2(1), 3 and 4; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3)

  4. Child competence or parental responsibility is assessed and recorded for under-16s and 16-to-17-year-olds, not treatment given without the assessment.

    Strong evidence: The children and young people record (the competence assessment, who gave consent and any disagreement that affected the decision), using the Gillick competence or parental-responsibility route.

    Weak evidence: A parent's signature on the form for a fourteen-year-old with no note of whether the child was assessed as having enough understanding for the treatment proposed, and a sixteen-year-old's treatment consented to by the adult who accompanied them. Records that capture the child's age but never mention competence, or a "parent consented" line that does not name the person or say on what basis they held parental responsibility.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. Consent is taken by someone competent to explain the treatment and answer the patient's questions, and within their scope of practice, not delegated to staff who only support the administrative parts.

    Strong evidence: The 'who can take consent' allocation (dentists for treatment they prescribe or provide, therapists and hygienists within their General Dental Council (GDC) scope, nurses and reception supporting administrative parts only), checked against current GDC scope.

    Weak evidence: A dental nurse's or hygienist's initials against the consent entry for treatment the dentist prescribed, or consent forms handed over, explained and signed at reception with the clinician countersigning afterwards. A scope-of-practice list written when the person was recruited and never rechecked against their current General Dental Council (GDC) registration and post-registration qualifications.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. Specific, purpose-named consent is recorded for photographs, image use and treatment by trainees, not bundled into general treatment consent.

    Strong evidence: The photography, scans and trainees consent record (the purpose, where the image or recording is stored, who may see it and whether it can be withdrawn).

    Weak evidence: A single "photographs" tick-box on the general treatment-consent form, so nothing distinguishes images going to a laboratory or referral from images used on the practice website or social media. Clinical images held on a personal phone or an open shared drive with no record of where they are stored, who may see them or that the patient was told consent can be withdrawn, and no mention of trainee or observer involvement, so the record cannot show the patient knew who would be treating them.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

Related

Last verified 20 July 2026

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Last reviewed 10 June 2026