• Full Name: ______________________________________________________
• Date of Birth: //_______
• Address: ______________________________________________________
• Phone Number: ___________________________
• Email Address: ___________________________
   

Procedure Details:

I, the undersigned patient, hereby consent to undergo the dental implant placement procedure under the care of Dr. ________, License Number _________, at Dental Implant Doctor Practice, located at 295 King St, London W6 9NH.

Nature of the Procedure: I understand that the dental implant placement procedure involves the surgical insertion of a dental implant into my jawbone to serve as an artificial tooth root for the subsequent attachment of a prosthetic tooth or crown.

Benefits and Risks: I acknowledge that the potential benefits of this procedure may include improved oral function, enhanced aesthetics, and the restoration of my dental health. However, I am also aware that, like any medical procedure, dental implant placement carries certain risks and potential complications, which may include but are not limited to:

• Infection at the implant site.
• Nerve or blood vessel injury.
• Implant failure or rejection.
• Complications during the healing process.

Alternatives: I have been informed of alternative treatment options, including but not limited to dental bridges and removable dentures, as well as the potential consequences of not undergoing implant placement.

Procedure and Anesthesia: I understand that the dental implant placement procedure will be performed under local anesthesia to ensure my comfort and minimize pain during the surgery.

Aftercare and Follow-Up: I am aware that the successful outcome of this procedure may depend on my adherence to post-operative care instructions and regular follow-up appointments with my dentist to monitor the healing process and the integrity of the implant.

Financial Responsibility: I acknowledge that I am responsible for the cost of the implant placement procedure, and I have been informed of the financial implications associated with this treatment.

Patient Consent: I have had the opportunity to discuss the procedure, its alternatives, benefits, and risks with Dr. [Dentist's Last Name]. I have been provided with the opportunity to ask questions and seek clarification on any aspect of the procedure. I understand the nature of the dental implant placement procedure and its associated risks and benefits, and I voluntarily provide my informed consent for this treatment.

Patient's Signature: __________________________

Date: //_______

Consent Witness (if applicable):

• Full Name: ___________________________
• Relation to Patient: ___________________
• Witness's Signature: ___________________

Please feel free to adapt this consent form as needed to align with your specific practice's requirements and regulations. Always ensure that the patient fully comprehends the procedure and associated risks before obtaining their consent.