Patient Consent - Dental Implant Surgery printable pdf download

Patient Consent - Dental Implant Surgery

PATIENI'CONSENT

Dental Implant Surgery

I hereby authorize Dr._____________and such assistants or associates as may be selected by him, to

remedy or treat the condition or conditions which appear indicated by diagnostic studies.

I have been fully informed of the nature of root form implant surgery, the procedure to be utilized, the risks

and benefits of periodontal and implant surgery, the alternative treatments available, and the necessity for

follow-up and self care. I have had an opportunity to ask any questions I may have in connection with the

treatment and to discuss my concerns with my periodontist. After thorough deliberation, I hereby consent to

the performance of dental implant surgery as presented to me during consultation and in the treatment plan

presented to me.

I also consent to the use of an alternative implant system or method if clinical conditions are found to be

unfavorable for the use of the implant system that has been described to me. If clinical conditions prevent

the placement of implants, I defer to my periodontist's judgment on the surgical management of that

situation. I also give my permission to receive supplemental bone grafts or other types of grafts to build up

the ridge of my jaw and thereby to assist in placement and security of my implants.

No Warranty or Guarantee. I hereby acknowledge that no guarantee, warranty or assurance has been

given to me that the proposed treatment will be successful, Due to individual patient differences, a therapist

cannot predict certainty of success. There exists the risk of failure, relapse, additional treatment, or

worsening of my present condition, including the possible loss of certain teeth or implants, despite the best

care.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.'

Date________Patient/Guardian_______________Doctor________________________Witness_________

Patient Consent - Dental Implant Surgery