Download Dental Implant Consent Form - Sample Forms

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					Dental Implant Consent Form
Name of the Clinic:

Name of the Dentist: Dr.

Department:                               Referred by:

Date:                 Time:

                            Details of the Patient

Name:                                                   Age:

Address:                                       City:

State:                                         Zip:

Home Phone:                                    Cell Phone:

Sex:                  Marriage Status:

Dental Insurance Details:

In case of emergency who should be notified:

                 Patient’s Dental Details and Medical History

Date of last dental exam:                 Diagnosis:

Previous Dental Implant

Type of previous dental        Root-form endosseous implant
implant surgery
                               Blade endosseous implant

                               Subperiosteal implant

Previous Implant surgery
to support:
                               Crowns

                               Dentures

                               Implant supported Bridges

Health      of     previous
Implant

Previous             surgery   Institution/Clinic/Hospital:
performed by:

                       Patient’s Current Dental Details

Patient’s Current
Dental Assessment
Current oral health
assessment

CT Scan result

CT Scan Report
attached

Type of treatment
                           Replacement - Single Tooth

                           Replacement - Multiple Teeth

                           Replacement - All Teeth (Lower Jaw / Upper Jaw)

                           Sinus Augmentation

                           Ridge Modification
Type of Surgical           Endosteal (in the bone)
Procedure
                           Subperiosteal (on the bone)
First stage surgery        Results:

Second stage               Results:
surgery

Pre-surgery
medication

Post-surgery
medication

Type of Anesthesia to use:

                            Dental Implant Consent

I have been informed about the various risks and complications from the dental
implant surgery, use of prescribed drugs, and anesthetics. I also understand that
there can be surgical complication possibilities including oral infection, alteration
in taste, tissue discoloration, numbness, increased sensitivity of the tongue, lips,
chin, or teeth. I hereby state that I have read the form and I fully understand it. I
have also been given the opportunity to ask questions regarding the implant and
they have been answered to my satisfaction.

Signature

Patient / Legal Guardian     Date



Signature

Doctor / Dental Surgeon     Date

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