Draft · Review before use
Informed Consent for Dental Implant Surgery
Patient:
Age / Sex: / Female
Date: 9 October 2026
Treating clinician:
Tooth / Site: —
1. Nature of the procedure
Surgical placement of a titanium implant fixture into the jawbone to replace a missing tooth. After a healing period, an abutment and crown will be attached. Additional bone grafting may be required.
2. Expected benefits
Restoration of chewing function and appearance, preservation of jawbone, and a long-lasting fixed replacement.
3. Risks and possible complications
Pain, swelling and bruising; bleeding; infection; damage to adjacent teeth; temporary or permanent numbness of the lip, chin or tongue; sinus involvement (upper jaw); failure of the implant to integrate requiring removal.
4. Alternative treatment options
No treatment, removable partial denture, or fixed bridge.
5. Anaesthesia
Local anaesthesia, with or without sedation as discussed.
6. Post-operative instructions
Avoid smoking, follow prescribed medication, maintain oral hygiene, eat soft foods and attend all review appointments.
7. Patient declaration
I confirm that the nature, purpose, benefits, risks and alternatives of the above procedure have been explained to me in a language I understand. I have had the opportunity to ask questions and all my questions have been answered satisfactorily. I understand that no guarantee has been given regarding the outcome. I voluntarily consent to undergo the procedure.
Photography & videography: Clinical photographs and videos may be taken for your treatment records only; they will not be used for marketing or any other purpose without your separate written consent.
Patient / Guardian signature
Name: ______________________
Clinician signature
Name: ______________________
Witness signature
Name: ______________________
This document is a draft generated for convenience and must be reviewed by a qualified clinician before use.