Dental Implant Consent Form

Dental Implant Consent Form
Purpose of the Consent:
To provide written information regarding the risks, benefits, and alternatives of the treatment this consent is written. It is important that the patient should fully understand the treatment priorly. Before signing the consent, the patient should ask any of the questions regarding the treatment, dental implant and procedures to their doctor or healthcare professional.
The Treatment Information:
As a surgical fixture dental implant is placed into the jawbone and allowed to fuse with the bone for a few months. The dental implant can be seen as artificial replacement for missing tooth root to hold a replacement tooth or bridge.
Risks and Side Effects:
The possible side effects are listed below. However, the patients should be aware that there may be unique effects to certain people that are not known right now.
• Infection
• Gum recession
• Loose implant
• Nerve or tissue damage
• Sinus issues (pain, tenderness, or swelling around the cheeks, eyes, or forehead
green or yellow nasal mucus, a blocked nose, a reduced sense of smell, sinus headaches, toothache, bad breath, a high temperature)
• Damage from excessive force
Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Gender
FemaleMaleOther
I, the undersigned, agree with the following statements.
I have been given enough information about the treatment I am to receive and informed about the procedure. I got the detailed explanation of the procedure I am to undergo. I understand the aims and objectives of the treatment completely.They have given me the opportunity to ask all remaining questions I may have about the treatment, and I answered them to the best of their ability.Having considered all aspects, I have decided to have this treatment of my own accord. I understand that I will not be able to sue my doctor in case of any complications or be entitled to a refund if I am not happy with my procedure.If signing for someone other than myself, I confirm that I am the parent / legal guardian or substitute decision maker.I AM GIVING CONSENT TO RECEIVE THE DENTAL IMPLANT TREATMENT.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: