Case Acceptance Form

About this form

The case acceptance form is a clinical & charting document used by dental practices. Patient acknowledgment and acceptance of recommended treatment plan. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 8 fields:

• Patient Name — Text
• I have reviewed the proposed treatment plan — Multiple choice
• I understand the estimated costs and payment options — Multiple choice
• I accept the recommended treatment — Multiple choice
• I understand I can ask questions at any time — Multiple choice
• Treatment Coordinator Name — Text
• Patient Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the day-to-day office workflow. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.