Form

INFORMED CONSENT FOR IMPLANTS

COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or alcohol intake may affect healing and may limit the successful outcome of my surgery. I agree to follow instructions related to the daily care of my mouth. I agree to report for appointments following my surgery as suggested so that my healing may be monitored, and the doctor can evaluate and report on the outcome of my surgery upon completion of healing.

SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, filming, recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures or publications, provided my identity is not revealed.

CONSENT FOR THE PLACEMENT OF DENTAL IMPLANTS

PATIENT'S ENDORSEMENT: My endorsement (signature) to this form indicates that I have read and fully understand the terms and words within this document and the explanations referred to or implied, and that after through deliberation, I give my consent for the performance of any and all procedures related to the placement of dental implant(s) as presented to me during the consultation and treatment plan presentation by the doctor or as described in this document.

CONSENT TO UNFORESEEN CONDITIONS: During surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to extraction of additional teeth or termination of the procedure prior to the completion of the extraction/surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the treating doctor.

Patient's Signature

Date

Patients Name

First Name

Last Name

Date Of Birth