DENTAL IMPLANT CONSENT FORM

This procedure has been recommended to me by my dentist as an option to replace my natural teeth.

I understand that there are potential risks, complications and side effects associated with any dental procedure.

  • Infection at the implant site.
  • Injury or damage to surrounding structures, such as other teeth or blood vessels.
  • Nerve damage, which can cause pain, numbness or tingling in your natural teeth, gums, lips, or chin.
  • Sinus problems, when dental implants placed in the upper jaw protrude into one of your sinus cavities.

I have been informed of some of the possible risks, complications, and side effects of dental implant surgery.

It has been explained to me and I understand that a perfect result is not guaranteed and or warranted.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

  • Pre and post-treatment instructions have been explained to me.
  • I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
  • I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
  • Must notify the clinician if my medical history changes prior to subsequent treatments.
  • I consent to clinical photographs being taken of my treated areas for my personal health record only.
  • There are no refunds for services rendered and/or after a year from purchase and not used.
  • The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.



Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date