About this template
This Tooth Whitening Consent Form is designed for dental offices and cosmetic dentistry providers to streamline patient intake and ensure safety. It captures essential patient demographics, current dental health status, and medical history—including allergies and medications—which are critical for determining candidacy for whitening treatments.
Beyond basic intake, this template includes a comprehensive consent section. Patients can review the risks and requirements of the procedure and provide their formal agreement. By using this Doc2Form template, dental professionals can maintain organized digital records, minimize liability, and ensure every patient is fully informed before beginning their whitening treatment.
Key features
- Captures comprehensive dental health and medical history.
- Includes a dedicated section for informed consent and liability waiver.
- Collects essential patient contact information for follow-ups.
- Easy to share via email or QR code at the front desk.
- Automatically saves all responses to a secure Google Sheet.
Use cases
- Pre-procedure patient screening for cosmetic whitening.
- Documenting informed consent for dental office compliance.
- Updating patient medical and dental history records.
- Collecting digital signatures for treatment waivers.
What this form collects
- Patient Full Name (Short answer)Please enter your legal first and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Contact Information (Short answer)Provide your preferred email and phone number for appointment confirmation.
- Dental Health Status (Checkboxes)Check all that apply to your current dental condition.
- Medical History (Paragraph)Please list any known allergies, current medications, or pre-existing medical conditions.
- Informed Consent (Multiple choice)I understand the risks and benefits of the tooth whitening procedure and agree to proceed.
- Digital Signature (Short answer)By typing your full name here, you are providing your electronic signature for this consent form.
- Date Signed (Date)Select today's date.
FAQ
Can I add my own dental practice branding?
Yes. Once you generate the form, you can easily customize the header image, colors, and fonts within the Google Forms editor to match your practice's branding.
How do I collect a physical signature?
Google Forms does not have a native 'draw' signature field. We recommend using a checkbox for 'I agree to the terms above' combined with a text field for the patient's full name as a digital signature.
Can I export this data to my practice management software?
Yes, all responses are saved to a Google Sheet, which can be exported as a CSV or Excel file to be imported into most dental practice management systems.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.