Consent for a Clinic or Dental Procedure — Form and Record
One page: what, why, the alternatives, the risks that matter, the questions asked, the signature — and the interpreter line
What it is
A consent form for ambulatory and dental procedures with the elements the Informed Consent Policy requires: procedure and purpose in plain words, benefits, risks (common and serious), alternatives including no treatment, anaesthesia, the patient's questions, teach-back, interpreter, and signatures.
Where to use it
Before every listed procedure; in the record; audited quarterly under the Consent Policy. Evidence for: Universal Floor — informed consent; Ambulatory Standard 4. Evidence for: Universal Floor — informed consent; Ambulatory Standard 4. Evidence for: Universal Floor — informed consent; Ambulatory Standard 4. Evidence for: Universal Floor — informed consent; Ambulatory Standard 4.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
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Minor Procedure Safety Checklist — Clinic and Dental
Dental Infection Control — Instrument Reprocessing and Waterline Checklist
Clinic Emergency Box — Contents and Monthly Check
Referral Letter Template and Referral Tracking Log
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