Implant patient information and consent form

Implant patient information and consent form

Implant patient information and consent form

  1. I have been informed and I understand the purpose and the nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.
  2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained.  I have tried or considered these methods, but I desire an implant to help secure replaced missing teeth.
  3. I have further been informed of the possible risks and complications involved with the surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration.  Numbness of the lip, tongue, chin, cheek, or teeth may occur.  The exact duration may not be determinable and may be irreversible.  Also possible are inflammation of a vein, injury to teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medications used, etc.
  4. I understand that if nothing is done, any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth, followed by necessity of extraction.  Also possible are temporomandibular joint (jaw) problems, headache, referred pain to the back of the neck and facial muscles, and tired muscles when chewing.
  5. My doctor has explained that there is no method to accurately predict the gum and the bone healing capabilities in each patient following the placement of the implant.
  6. It has been explained that in some instances implant fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; no guarantee or assurance as to the outcome of results of treatment or surgery can be made.
  7. I understand that excessive smoking and alcohol may affect gum healing and may limit the success of the implant. Also, old age patients may have lower success rates.  I agree to follow my doctor’s home care instructions.  I agree to report to my doctor for regular examination as instructed.
  8. I agree to the type of anaethesia according to the choice of the doctor.
  9. To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any allergic or unusual reactions to drugs, food, anesthetics, abnormal bleeding or any other conditions related to my health.
  10. I approve any modification in the treatment plan, if it is felt this is for my best interest.



Signature of doctor:

Signature of the patient or the patient’s relative:





Dr. Aly Badr

 BDS, MDSc Fixed Prosthodontics

Dental care clinic – 151 El Higaz st, Heliopolis, Cairo, Egypt      Tel:01007512728




151 Elhegaz st.Heliopolis


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