PRE OPERATIVE CONSENT
1. Surgical Consent
I agree to allow Doctor _________________________ to practice the following surgical
procedure(s): __________________________________________________________________.
He has explained the risks and benefits associated with this procedure i.e. : swelling, pain,
bleeding, infections, muscle spasms ( temporary or ever permanent) numbness resulting from
nerve injury.
For implant placement,
The surgeon has advised me that there is no predictable method of determining how the bone and
gums will heal after implant placement. It was explained that, at times, an implant may not
integrate and its removal may be required.
I was informed and understand that treatment results cannot be guarantied as they pertain to
surgery.
_____/_____/_______________________________________________
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Patient or guardian
2. Consent for local anesthetic and/or i.v. sedation
I agree to allow Doctor ____________________________ to give me the necessary
medications_________________________________________________ necessary to practice the
above mentioned surgery :
_____/_____/________________________________________________
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Patient or guardian
__________________________________________
Surgeon
__________________________________________
Witness
JEAN FRANÇOIS BAYLARD, B.Sc., D.M.D., M.Sc. dip. paro.
GUY CARON, D.M.D., dip. chir. buc. max-fax. F.R.C.D. (c)
NORMAN PIERRE EDGER, D.D.S., dip. chir. buc. max-fac., M.R.C.D.(c)
FRANÇOIS PAYETTE, D.M.D., dip. Chir. Buc. max-fac., F.R.C.D.(c)