Denture Consent Form

Denture Consent Form
Patient Information
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
MonthDayYear
Date
Dentist Information
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Licence Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Purpose of the Denture:
The purpose of the denture is to replace missing teeth and restore oral function and appearance.
Procedure Description:
The denture procedure involves taking impressions of the mouth, creating a mold of the denture, and fitting the denture into the mouth. The process may take several appointments to complete.
Risks and Complications:
Potential risks and complications associated with the denture procedure may include bleeding, infection, or allergic reactions. Additionally, the denture may need to be adjusted or repaired over time.
Benefits of the Procedure:
The benefits of the denture procedure include improved oral function, such as better ability to chew and speak, and improved appearance, including a more natural smile.
Follow-up Care:
After the denture procedure, it may be necessary to return for adjustments or maintenance appointments. Proper care and cleaning of the denture can also help ensure long-term success.
Consent Statement
I have read and understand the information provided above regarding the denture procedure, its risks and benefits, and any necessary follow-up care. I have had the opportunity to ask questions and have had them answered to my satisfaction. I hereby consent to the denture procedure.
Date
MonthDayYear
Date
Patient Signature
Clear
Should be Empty:

Denture Consent Form

Patient Information

Dentist Information

Consent Statement