Signing example
Sign a dental treatment consent online
A dental treatment consent has to show that the patient understood the risks, had questions answered and knew what the plan would cost before any work started. This three page consent for a root canal and crown on one molar carries the full fee table with item numbers, three statements the patient marks with an X, and the dentist's countersignature.
The document, with its fields
The pages as a signer sees them, with the signature, name, title and date fields placed where each party has to complete them.
Consent to Dental Treatment
1. Patient and dentist
| Patient | Lachlan Whitford, date of birth 14 March 1988, patient number HFD-20733 |
|---|---|
| Treating dentist | Dr Anika Rasmussen, general dentist, Harbourview Family Dental |
| Tooth | Lower left first molar, tooth 36 |
| Diagnosis | Irreversible pulpitis under a large, failing amalgam filling, confirmed by examination, cold testing and two periapical radiographs taken on 29 September 2026 |
2. The proposed treatment
Root canal treatment of tooth 36 over two visits, followed by a ceramic crown fitted over two further visits once the tooth has settled. The canals are cleaned, shaped and disinfected at the first visit and sealed at the second.
3. Treatment plan and fees
Item numbers are from the Australian Schedule of Dental Services and Glossary, which health funds use for rebates.
| Item | Service | Qty | Fee | Visit |
|---|---|---|---|---|
| 013 | Oral examination, limited | 1 | $70.00 | Done 29 Sep |
| 022 | Intraoral periapical radiograph | 2 | $92.00 | Done 29 Sep |
| 415 | Chemo-mechanical preparation, one canal | 1 | $360.00 | Visit 1 |
| 416 | Chemo-mechanical preparation, each additional canal | 2 | $380.00 | Visit 1 |
| 417 | Root canal obturation, one canal | 1 | $250.00 | Visit 2 |
| 418 | Root canal obturation, each additional canal | 2 | $240.00 | Visit 2 |
| 613 | Full crown, non-metallic, indirect | 1 | $1,650.00 | Visits 3 and 4 |
| Total estimated fee | $3,042.00 | |||
| Already paid for the examination and radiographs | $162.00 | |||
| Remaining fee for this plan | $2,880.00 | |||
4. Other options
| Option | What it involves | Fee |
|---|---|---|
| Extraction | Removing tooth 36. A gap is left, or later replaced with an implant or bridge at further cost | $320.00 |
| Referral to an endodontist | A specialist performs the root canal treatment; the crown is then done here | Quoted by the specialist |
5. Risks of root canal treatment and crowns
Root canal treatment succeeds in most teeth, but no dentist can promise a result. The risks Dr Rasmussen discussed with the patient on 29 September 2026 are below. Leaving the tooth untreated is also an option, but pain is likely to continue and infection may spread to the jaw, so it is not recommended.
| Risk | What it means for tooth 36 |
|---|---|
| Post treatment tenderness | The tooth may be sore to bite on for a few days after each visit. Over the counter pain relief usually controls it. |
| Flare up | Occasionally swelling and pain develop between visits and need an extra visit or antibiotics. |
| Instrument separation | A fine file can break in a curved canal. It is usually left sealed in place or bypassed, and rarely affects the outcome. |
| Perforation or missed canal | Uncommon. It may need specialist referral and can lower the chance of success. |
| Nerve numbness | Lower molars sit close to the inferior alveolar nerve. Temporary numbness of the lip or chin is rare; permanent numbness is very rare. |
| Fracture before the crown | A root filled tooth is brittle until crowned. Chewing hard food on that side before visit 3 risks a split tooth that cannot be saved. |
| Failure later | Infection can return months or years later and need retreatment, surgery or extraction. |
| Crown changes | The crown may chip, loosen or need replacing in time, and its shade is matched to the neighbouring teeth as closely as possible. |
6. What the patient confirms
The patient types an X in each box below, in their own signing session, for each statement they agree with. A box left empty means the patient wants to talk to the dentist again before treatment starts.
| Agree | Statement |
|---|---|
| The risks in clause 5, and the other options in clause 4, have been explained to me in a way I understand. | |
| I have had the chance to ask questions and my questions have been answered. | |
| I understand the estimated fee of $3,042.00, that $2,880.00 remains to be paid, and that my health fund's rebate is not known until the claim is made. |
7. Payment
Fees are payable at each visit for the items done at that visit. The practice claims the health fund rebate on the spot where the patient presents their membership card, and the patient pays the gap. If the treatment changes, for example because a fourth canal is found, the dentist explains the change and its fee before doing it, and the patient may decline. Item 416 and item 418 would each then be charged three times rather than twice.
8. Cancellations
Each visit is booked for a long appointment. Please give 24 hours' notice of a cancellation. A visit missed without notice may be charged at $80.00. Leaving the temporary filling in place for longer than eight weeks before the crown increases the risk of fracture and reinfection, so visits 3 and 4 should not be postponed for long.
9. After each visit
- Avoid eating until the local anaesthetic has worn off, so you do not bite your lip or cheek.
- Chew on the other side until the crown is fitted.
- Call the practice on 07 4772 1180 if swelling develops, if pain gets worse after three days, or if the temporary filling comes out.
10. Records and privacy
The radiographs, this consent and the clinical notes are kept in the patient's record for at least seven years after the last visit, under the Australian Privacy Principles and the practice's privacy policy. A copy of this signed consent is emailed to the patient when the dentist countersigns.
11. Consent
I consent to Dr Anika Rasmussen performing root canal treatment and a crown on tooth 36 as set out in this plan, including local anaesthetic and any further radiographs needed during treatment. I understand I may withdraw this consent at any time before or during treatment.
Who signs what
- Lachlan Whitford, patient
- Three X marks on page 2: risks and options, questions, costs · Signature and stamped date on page 3 · Email link
- Dr Anika Rasmussen, treating dentist
- Signature block on page 3: Name, Title and a stamped Date · Email link
The signing journey
Step 1
Six fields across two pages
Three checkboxes in the Agree column on page 2, then a signature and date for the patient and a three line block for the dentist on page 3.
Step 2
The patient goes first
Sign in order is on. Only Lachlan is invited at send, and the dentist's link waits for his signature.
Step 3
Three statements, three X marks
He types an X beside each statement he agrees with. An empty box would have told the practice he wanted to talk again before treatment.
Step 4
The dentist countersigns
Dr Rasmussen's block prints Treating dentist as its heading, her name, the title she types and the stamped date.
Every field, and who fills it
Lachlan Whitford types an X into three boxes in the Agree column on page 2: risks and options explained, questions answered, and costs understood. On page 3 he draws his signature under the consent paragraph and the date is stamped below it. Dr Anika Rasmussen signs a block beside his, headed Treating dentist, with her name from the recipient record, General Dentist typed as her title and a stamped date. The diagnosis of tooth 36, the seven items and every fee are printed.
How to adapt this envelope
A practice with a hygienist or a specialist on the plan adds them as a third recipient with their own block, so each clinician countersigns the part they perform. A plan that will change partway, such as an implant after an extraction, is better as two envelopes, one per stage, each with its own fee table. For a minor patient, the parent becomes the first recipient and the consent paragraph says they sign on the child's behalf.
What makes this valid in Australia
The Electronic Transactions Act 1999 recognises an electronic signature that identifies the signer and shows intention, by a reliable method. Informed consent itself is a clinical and legal duty set by the Dental Board of Australia's code of conduct and described in the national guidance on informed consent: a signature records the conversation rather than replacing it. Financial consent, telling the patient the cost before treatment, is part of the same duty.
What makes this signing flow work
The fees are part of the consent
Item 013, 022, 415, 416, 417, 418 and 613 are listed with quantities and fees, totalling $3,042 with $2,880 still to pay. Consent to treatment and agreement to its cost sit in one signed document, which is what separates this from a general medical consent.
Costs get their own X
The third statement confirms he understands the estimated fee, the remaining amount and that his health fund rebate is not known until claimed. It is a separate mark from the risk statement, so financial consent is recorded on its own.
Patient first, dentist last
The dentist's signature confirms she explained the plan to someone who had already agreed to it. With the order on, the event log shows his signature landing before her invitation went out.
Questions people ask
Does a dental consent need the fees on it?
Dentists are expected to discuss costs before treatment, and putting the item numbers and fees on the consent means the patient's agreement to the cost is recorded at the same moment as their agreement to the treatment. It also gives the health fund claim and the patient the same numbers.
What if the patient leaves one of the three boxes empty?
The wording on page 2 says an empty box means he wants to talk again, but in this envelope all three boxes were left required, so the portal will not let him finish with one empty; he would call the practice instead. To allow an empty box, switch Required off for each checkbox.
Can the patient sign at home before the first visit?
Yes. The link goes to his email and he can read all three pages, mark the boxes and sign on any device. The dentist's countersignature follows, and the certified copy reaches both of them by email well before the first appointment on the plan.
What does the certificate show about the patient's consent?
His verification method, here Email link, the time he signed, the IP address, the time and version of the electronic signing consent he accepted, the hash of the document at signing and the hash of his signature image, plus every event in order.
What happens if a fourth canal changes the fee?
Clause 7 says the dentist explains the change and its fee first, and the patient may decline. The signed consent cannot be edited after completion, so a large change is best recorded as a short new consent sent as its own envelope.
What if the patient declines the plan?
The envelope moves to declined and the practice is emailed with any reason he typed. The dentist is never invited, no treatment is consented to, and the practice can offer the other options in clause 4 in a new envelope.
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