How to Record Consent in Dental Notes (with Examples)

Dental consent documentation is the written record proving that valid informed consent was obtained before treatment. Since the Montgomery v Lanarkshire ruling in 2015, the law requires clinicians to take reasonable care that the patient knows about any material risks of the recommended treatment and any reasonable alternatives, where a risk is material if a reasonable person in the patient’s position, or this particular patient, would be likely to attach significance to it. For dentists, this means documenting not just that consent was obtained, but exactly what was discussed — treatment options, risks, benefits, alternatives, and the patient's decision.

Consent failures are among the most common findings in GDC fitness to practise cases and dento-legal claims. The clinical record is the only evidence that a consent discussion took place. A note reading "consent obtained" is no longer sufficient — and has not been since 2015. This article sets out the legal and regulatory framework for dental consent in the UK, what must be documented, and how to write consent records that are defensible under scrutiny.

Montgomery in two lines

Montgomery v Lanarkshire Health Board [2015] UKSC 11 replaced the Bolam test for consent with a patient-centred one: the clinician must take reasonable care to ensure the patient is aware of any material risks of the recommended treatment and of any reasonable alternative or variant treatments (para 87). The legal test, the therapeutic exception and the material risks to discuss by procedure are set out in Montgomery in dentistry: the legal test and material risks. This page is about what to write in the record.

GDC principle 3: obtain valid consent

The General Dental Council's Standards for the Dental Team addresses consent directly under Principle 3: "Obtain valid consent." This is a regulatory obligation — not guidance. Failure to comply can result in fitness to practise proceedings and sanctions on your registration.

Principle 3 requires dental professionals to:

• Explain all relevant treatment options — including the option of no treatment, with the advantages and disadvantages of each
• Explain possible costs — ensuring patients understand the financial implications of their treatment choices, including NHS versus private options where applicable
• Ensure the patient understands — consent is not valid if the patient does not understand the information provided. The clinician must check comprehension, not merely deliver information
• Ensure consent remains valid at each stage — consent is not a single event but an ongoing process. If treatment plans change, or if there is a significant delay between consent and treatment, consent must be renewed
• The treating clinician confirms consent — GDC Standard 3.1.1: you must make sure you have valid consent before starting treatment, and must not assume a colleague has obtained it. If a trained colleague helps with the consent discussion, you remain responsible for confirming it
• Document consent in the clinical record — GDC Standard 3.1.2 says you should document the consent discussion, and 3.3.4 says you must document discussions confirming ongoing consent. A verbal discussion that is not documented is very hard to evidence later

The GDC also emphasises that consent must be given freely, without pressure or undue influence. Patients must be given adequate time to consider their options. Rushing a consent discussion — particularly for irreversible procedures — undermines its validity.

What to document for valid consent

A defensible consent record must demonstrate that the discussion took place, what was covered, and what the patient decided. The following checklist covers the elements that dental defence organisations, GDC panels, and expert witnesses expect to find in the clinical record (for the forms themselves see our dental consent forms guide, and for how consent records are tested in a claim see medico-legal dental notes):

1. Treatment proposed — specific to the tooth and procedure, not a generic treatment plan reference (e.g. "extraction of LL6" not "extractions as discussed")
2. Alternative treatments discussed — including no treatment, with a brief note of why each was or was not suitable
3. Risks of proposed treatment — material risks specific to the procedure, documented individually rather than as "risks explained"
4. Benefits of proposed treatment — what the patient can expect to gain from the procedure
5. Risks of alternatives — including the risks of each alternative option that was discussed
6. Risks of no treatment — what may happen if the patient declines all treatment, including potential deterioration
7. Expected outcomes and prognosis — realistic expectations, including guarded or poor prognosis where applicable
8. Patient's questions and your answers — documenting specific questions the patient asked demonstrates genuine two-way dialogue
9. Patient's decision — which option the patient chose and confirmation that the decision was made freely
10. How consent was given — whether verbal, written, or implied by compliance (and when written consent is appropriate)
11. Whether a written consent form was signed — for surgical or complex procedures, noting that a signed form supplements but does not replace the clinical record entry

Consent documentation examples

The difference between defensible and indefensible consent documentation is stark. These examples illustrate the contrast.

Poor consent note

This note provides no evidence of what was discussed. It does not identify which tooth, what risks were explained, what alternatives were offered, or whether the patient understood. In a GDC hearing or negligence claim, this note offers no protection whatsoever.

Good consent note

This note documents the specific tooth, each treatment option with its risks and benefits, the no-treatment option, the patient's understanding, their decision, and the consent method. Every element a panel or expert witness would look for is present.

Common consent documentation failures

The same consent documentation failures recur. These are mistakes that can lead to adverse findings:

1. "Consent obtained" with no detail — The most frequent failure. This phrase documents that something happened but provides no evidence of what was discussed. It is insufficient under Montgomery and fails to meet GDC Principle 3.
2. No alternatives documented — Recording only the treatment provided, without noting what alternatives were discussed and why the patient chose this option. The GDC requires that patients are given genuine choices.
3. No risks documented — Recording that "risks were explained" without specifying which risks. This provides no evidence that material risks were disclosed and is inadequate under the Montgomery standard.
4. Consent taken by someone other than the treating clinician — A dental nurse or receptionist handing a consent form to a patient for signature, without the treating clinician verifying the patient's understanding. The form may be signed, but consent may not be valid.
5. Consent not renewed when treatment plan changes — An initial consent discussion covered a filling, but during treatment the decision was made to extract. The record shows consent for a filling but not for the extraction that was actually performed.
6. No documentation of patient understanding — Recording what was said to the patient but not whether the patient understood it. The GDC requires that clinicians check comprehension, particularly for patients with communication difficulties or those for whom English is not their first language.
7. Consent for "treatment plan" rather than specific procedures — A single consent entry covering an entire multi-appointment treatment plan, rather than procedure-specific consent at each visit. Consent must be specific to the treatment being provided at that appointment.
8. Not re-consenting for multi-visit treatment — For procedures spanning multiple appointments (such as root canal treatment or implant placement), consent should be confirmed at each visit. The patient's circumstances, understanding, or wishes may change between appointments.

Special consent situations

Certain clinical scenarios require additional care in consent documentation. These situations carry higher medico-legal risk and are more likely to be scrutinised in complaints and claims.

Children and Gillick competence

For patients under 16, consent may be given by a person with parental responsibility. However, under the principle of Gillick competence (established in Gillick v West Norfolk and Wisbech Area Health Authority, 1985), a child who demonstrates sufficient understanding and intelligence to fully comprehend the treatment may consent independently. The record should document who gave consent, their relationship to the patient (if not the patient themselves), and where Gillick competence is relied upon, the basis for that assessment.

In England and Wales, a young person aged 16 or 17 can consent to their own dental treatment as effectively as an adult (Family Law Reform Act 1969, s8), and the Mental Capacity Act 2005 applies from 16. In Scotland, a person under 16 has legal capacity to consent to dental treatment where, in the opinion of a qualified medical practitioner attending them, they understand its nature and possible consequences (Age of Legal Capacity (Scotland) Act 1991, s2(4)).

Patients lacking capacity

Where a patient lacks capacity to consent, treatment decisions must be made in the patient's best interests under the Mental Capacity Act 2005 (England and Wales; in Scotland, the Adults with Incapacity (Scotland) Act 2000; in Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016). Capacity is decision-specific and time-specific — a patient may have capacity for some decisions but not others. The record must document: the assessment of capacity, who was consulted (family, carers, IMCA where applicable), the best interests decision and its rationale, and whether the treatment can be delayed until capacity returns.

Emergency treatment without consent

Emergency treatment to preserve life or prevent serious deterioration may be provided without consent where the patient is unable to consent and delay would be harmful. The record must clearly document the emergency, why consent could not be obtained, and why treatment could not be delayed. This exception is narrow — it does not apply to urgent but non-emergency care.

Consent for sedation

Sedation requires its own specific consent, separate from consent for the dental procedure itself. GDC Standard 3.1.6 requires written consent where treatment involves conscious sedation (including inhalation sedation) or general anaesthetic. The patient must understand the effects of sedation, the risks (including respiratory depression), the requirement for an escort, and post-sedation restrictions. Consent for sedation must be obtained before any sedative agents are administered — once sedated, the patient cannot give valid consent.

Withdrawal of consent during treatment

A patient may withdraw consent at any point during treatment. If this occurs, the clinician must stop the procedure at a safe point, explain any risks of stopping mid-treatment, and document the withdrawal of consent, the point at which treatment was stopped, what the patient was told, and the follow-up plan. Continuing treatment after consent is withdrawn constitutes battery (in England and Wales).

How Nosht handles consent documentation

Consent documentation failures are almost always failures of workflow rather than knowledge. Clinicians know they should document consent — the problem is that busy appointment schedules make it easy to skip or abbreviate. Nosht addresses this by building consent prompts directly into every treatment template:

• Treatment-specific consent sections — every template includes consent documentation prompts tailored to that procedure. Extraction templates prompt for extraction-specific risks; root canal templates prompt for endodontic-specific risks. The risks are not generic — they reflect what a Montgomery-aligned discussion requires for that treatment.
• Alternatives discussion prompted automatically — templates prompt for alternative treatment options, including no treatment, so that the consent record demonstrates genuine patient choice.
• Risk fields specific to the procedure — rather than a free-text "risks discussed" box, Nosht provides structured risk options relevant to the specific treatment, reducing the chance that material risks are omitted.
• Bulletproof Mode flags missing consent — when enabled, Nosht's documentation completeness check identifies notes where consent documentation may be incomplete or absent, alerting the clinician before the note is finalised.

The result is that a complete consent record structured to the Montgomery standard is a natural output of the documentation workflow — not something that requires additional effort to remember and include.

Frequently asked questions

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Further reading

• GDC Dental Records Requirements: What Every Dentist Must Document
• Dental Documentation Guide: FGDP Standards and Best Practice
• What Should Dental Notes Include?