Patient Consent Form
Patient Name: John Doe
Date of Birth: 15 March 1985
Procedure: Dental Implant Surgery
Clinician: Dr. Emily Carter
Date of Discussion: 1 November 2024
**1. Procedure Details**
The proposed treatment/procedure is Dental Implant Surgery, which involves the following steps:
- Extraction of the damaged tooth
- Placement of the titanium implant into the jawbone
- Attachment of the abutment and crown
**Estimated Cost:** £2,500
**2. General Risks and Considerations**
The following are general risks associated with this procedure:
- Swelling, pain, bleeding
- Infection, prolonged healing
- Nerve damage, reaction to anesthesia
**3. Patient-Specific Risks and Considerations**
During the consultation, we identified specific factors that may influence the outcome of this procedure based on your medical history, lifestyle, and oral health status. These factors may affect healing, long-term success, or the risk of complications.
Factors considered in your case include:
- Smoking habit: May delay healing and increase the risk of infection
- Diabetes: Requires careful monitoring of blood sugar levels to prevent complications
- Recommendation for improved oral hygiene to support healing
Your treatment plan has been customised based on these factors to minimise risks and optimize results. The potential impact of these factors on your treatment has been discussed with you, along with strategies to mitigate risks where possible.
**4. Recommendations & Preventative Measures**
To improve treatment success and minimise risks, we recommend the following:
- Smoking cessation to enhance healing
- Use of specific dental care tools, such as an antibacterial mouthwash
- Regular follow-ups to monitor progress and address any issues promptly
**5. Acknowledgment & Consent**
I, John Doe, have been informed about the nature of the procedure, associated risks, and alternative options where applicable. I understand the information provided, have had the opportunity to ask questions, and give my informed consent to proceed with the treatment.
Patient Signature: ____________________________
Date: ____________________________
Clinician Signature: ____________________________
Date: ____________________________
