Assent Form (Informal Decision Making) (Page 2 of 2) in pdf

Assent Form (Informal Decision Making) Page 2

Proposed Treatment plan

_________________________________________________________________________________________

Risks and Side effects

_________________________________________________________________________________________

Assent

I have been involved in a discussion regarding

__________________________________________

I reasonably assume that this person does not have the capacity to decide for themselves in this

instance. I have been involved in a decision making process with the dentist and believe that the

treatment as outlined above is in the best interest of this person. I have had the opportunity to ask

any questions.

Name______________________________________! Relationship__________________________________________

Date__________________________!

Signature____________________________________________________

Comment

_____________________________________________________________________________________

Clinician

Date__________________________!

Signature____________________________________________________

Name of second clinician, where second opinion sought_________________________________________________

Date__________________________!

Signature____________________________________________________

Assent Form (Informal Decision Making) Page 2