The undersigned, I/the patient's guardian............................,

have been informed by the Dentist ............................. about the diagnosis and treatment planning, alternative treatments, their outcomes, and possible side effects. I understood and accepted the proposed treatment. I have been informed and accepted that the plan might change due to new circumstances that may arise during the treatment.

I have been informed, understood, and accepted the potential risks if the treatment is not applied, the cost comparisons with alternative treatments, and that consultations from other doctors may be requested if deemed necessary.

All my questions regarding the treatment of myself/the person I am a guardian for have been answered. I have been informed that the success of the treatments depends on me, that I need to follow oral hygiene and recommendations at home, comply with advice on abandoning harmful habits, and use the prescribed medications in the correct dosage and duration. I understood and accepted these requirements.

I have been informed, understood, and accepted that the aim of the proposed treatments is to protect oral and dental health, that medical services will be conducted diligently, but that the outcome of medical procedures cannot be guaranteed.

I approved and accepted the dental treatments explained and accepted by me/my ward as described in the treatment planning above.

I have been thoroughly informed about patient rights and responsibilities, and doctor rights and obligations.
After accepting the treatment, I give permission for my/the ward's radiographs, photos, videos, and other documents to be used as anonymized data for educational and/or scientific purposes. I give/do not give (Please write "give" or "do not give" in your own handwriting) permission for personal data to be shared with third parties and institutions, including public institutions.
..................... (Please write "I have read, understood, and accept" in your own handwriting.)

Date                                                                :
Legal Representative of the Patient            :
(*- Degree of kinship) Name-Surname        :
Patient Name-Surname                                :
National ID Number                                      :
Address                                                         :
Phone                                                             :
Signature                                                       :

* Legal Representative: For those under guardianship, the guardian; for minors, the parents; in the absence of these, the first-degree legal heirs. (Please indicate the degree of kinship next to the name of the patient's relative.)

Doctor's Name-Surname :
Date                                   :
Signature                          :

CHANGES IN THE TREATMENT PLAN

On ......................, the following changes were made to the treatment plan as specified below. 

My dentist explained why the change in treatment is necessary, the risks involved, potential problems, alternative approaches, possible post-treatment changes, success probability, and events that may occur during the recovery process.

I accept/do not accept (Please write "accept" or "do not accept" in your own handwriting) the change in the treatment plan mentioned above.