Consent for treatment policy (dental)

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

• 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/

5. 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

6. 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.

7. 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.

8. 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.

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 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.

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.

• 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.

11. 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.

12. 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.

13. 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.

Operational controls to adapt

Roles and responsibilities

• Registered Manager: owns consent governance, makes sure the consent system is audited, and reviews complaints, incidents and improvement actions.
• Treating dentist or prescribing clinician: leads the consent discussion, explains diagnosis, options, material risks, costs and alternatives, and confirms consent remains valid.
• Dental therapist or hygienist: takes consent for care within scope and escalates questions outside scope to the prescribing dentist.
• Dental nurse: supports the process, checks forms and information leaflets are available, and records support given where locally agreed.
• Reception or treatment-coordinator staff: explain appointment, estimate and payment administration, but do not replace the clinician's consent discussion.

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:

• diagnosis, treatment option, no-treatment option, alternatives and referral option where relevant
• material risks, expected benefits, likely visits, treatment-plan changes and costs
• NHS or private status, estimate or treatment-plan reference and any finance or payment information given
• information leaflet, consent form, photograph, scan or radiograph consent reference where used
• capacity, child competence, parental responsibility, interpreter or accessible-information support where relevant
• patient questions, answers given, refusal, withdrawal or decision to defer treatment
• confirmation that consent remained valid at the start of treatment
• linked complaint, incident, safeguarding, risk or improvement-action reference

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.

• CQC Regulation 11: Need for consent
• GDC Standards for the Dental Team, Principle 3 (obtain valid consent)
• Montgomery v Lanarkshire Health Board consent principles
• Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9/contents)
• MCA Code of Practice (2007, update in consultation)
• Gillick and Fraser competence (for children and young people)
• Human Rights Act 1998, Article 8 (respect for private and family life), where relevant
• GMC decision-making and consent guidance where clinical
• CQC dental mythbuster 23, consent to dental treatment
• NHS consent to treatment, children and young people
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/11)

Related reading

• Related policy: Consent policy
• Related policy: Record keeping and documentation standards policy
• Related policy: Dental safeguarding policy
• Related policy: Incident reporting, investigation and learning policy
• Related policy: Risk management and risk register policy

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

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.