Dental Record Form

Dental Record Form Template for England and Wales

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Key Requirements PROMPT example:

"I need a Dental Record Form for my new private practice opening in March 2025, with emphasis on cosmetic dentistry procedures and integrated payment plan tracking for premium treatments."

Document background

The Dental Record Form is a fundamental document in dental practice management across England and Wales. It serves as the primary record-keeping tool for patient care, ensuring compliance with regulatory requirements and professional standards. This document is essential for maintaining accurate patient histories, treatment plans, and consent records, while meeting the requirements of the General Dental Council, NHS, and data protection regulations. The form must be maintained for each patient and updated regularly to reflect ongoing care and treatment modifications.

Suggested Sections

1. Patient Information: Basic demographic details, contact information, NHS number, date of birth, gender, address

2. Medical History: Comprehensive health status, medications, allergies, conditions, surgeries, and ongoing treatments

3. Dental History: Previous dental work, procedures, complications, and treatments received

4. Current Examination: Detailed findings from current dental examination including tooth charting, periodontal status, and oral health assessment

5. Treatment Plan: Proposed treatments and interventions, including options, risks, and benefits

6. Consent Documentation: Patient consent records, including informed consent for treatments and data processing

Optional Sections

1. Emergency Contact Information: Secondary contact details for vulnerable patients or complex procedures

2. Insurance Information: Details of dental insurance coverage for private patients or those with additional coverage

3. Radiograph Records: X-ray documentation and findings when imaging has been performed

4. Pain Assessment: Detailed pain history and assessment when patient presents with dental pain

Suggested Schedules

1. Medical History Questionnaire: Detailed patient-completed health questionnaire including medical conditions, medications, and allergies

2. Treatment Consent Forms: Specific consent forms for various dental procedures and treatments

3. Privacy Notice: GDPR-compliant information about how patient data is collected, processed, and protected

4. Treatment Cost Schedule: Detailed breakdown of treatment costs and payment arrangements for private treatments

5. Clinical Photography Consent: Specific consent form for taking and using clinical photographs

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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Authors

Alex Denne

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