Consent For Dental Implants
You have the right and the obligation to make decisions regarding your healthcare. Your dentist can provide you with the necessary information and advice, but as a member of the healthcare team, you must participate in the decision-making process. This form will acknowledge your consent to the treatment recommended by your dentist.
  1. I request and authorize the doctor mentioned above or his/her associates or assistants to perform the surgical placement of dental implants upon me. This procedure has been recommended to me by my dentist as an option to replace my natural teeth.
    Dental implants are metal anchors put inside the jawbone underneath the gun line. Small posts are attached to the implants and artificial teeth or dentures are fastened to the posts. Most patients need two surgical procedures to install implants. The first procedure involves drilling small holes into the jawbone and placing the anchors. A temporary denture may be worn for a few months while the anchors bond with the jawbone and the gums and
    bone heal. The second procedure will uncover the implants to allow for attachment of the posts. After the posts are in place, the replacement teeth, in the form of fixed or removable bridgework or a denture, are fastened to the posts. Depending on the condition of the mouth, bone grafting or guided tissue regeneration also might be necessary to install the
    anchors and posts. The potential benefits of the procedure include the replacement of missing natural teeth or supporting dentures.
  2. I have chosen to undergo this procedure after considering the alternative forms of treatment for my condition, which include no treatment at all, complete or partial dentures, or fixed or removable bridges. Each of these alternative forms of treatment has its own potential benefits, risks and complications which have been explained to me.
  3. I consent to the administration of anesthesia or other medications before, during or after the procedure by qualified personnel. I understand that all anesthetics or sedation medications include the very rare potential of risks or complications, such as damage to vital organs including the brain, heart, lungs, liver and kidneys; paralysis; cardiac arrest; and/or death from both known and unknown causes.
  4. I understand that there are potential risks, complications and side effects associated with any dental procedure. Although it is impossible to list every potential risk, complication and side effect, I have been informed of some of the possible risks, complications and side effects of dental implant surgery. These could include but may not be limited to the following:
    • Postoperative pain, discomfort and swelling
    • Bleeding
    • Postoperative infection
    • Injury or damage to adjacent teeth or roots of the teeth
    • Injury or damage to nerves in the lower jaw, causing temporary or permanent numbness and tingling or pain of the chin, lips, cheek, gums or tongue.
    • Restricted ability to open the mouth because of swelling and muscle soreness or stress on the joints in the jaw – temporomandibular joint (TMJ) syndrome
    • Fracture of the jaw
    • Bone loss of the jaw
    • Penetration into the sinus cavity
    • Mechanical failure of the anchors, posts, or attached teeth
    • Failure to implant itself
    • Allergic or adverse reaction to any medications

    Most of these risks, complications or side effects are not serious and do not occur frequently. Although these risks, complications and side effects occur only very rarely, they do sometimes occur and cannot be predicted or prevented by the dentist performing the procedure. Although most procedures have good results, I acknowledge that no guarantee has been made to me about the results of this procedure or the occurrence of any risks, complications or side effects.
    These potential risks and complications could result in the need to repeat the procedures; remove the implants; or undergo additional dental, medical or surgical treatment or procedures, hospitalization or blood transfusions. Very rarely, the potential risk and complications could result in permanent numbness, disability or death. I recognize that during the course of treatment, unforeseeable conditions may require additional treatment or procedures. I request and authorize my dentist and other qualified medical personnel to perform such treatment as required.

  5. I certify that I have read or had read to me the contents of this form. I have read or had read to me and will follow any patient instructions related to this procedure. I understand the potential risks, complications and side effects involved with any dental treatment or procedure and have decided to proceed with this procedure after considering the possibility of both known and unknown risks, complications, side effects and alternatives to the procedure. I declare that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.]

Check Us Out on Social Media

Book Now

Your First Name
Field is required!
Your Last Name
Field is required!
Your Email Address
Field is required!
Your Phone Number
Field is required!
  • Preferred time slot
  • 9 a.m - 10 a.m
  • 10 a.m - 11 a.m
  • 11 a.m - 12 p.m
  • 12 p.m - 1 p.m
  • 1 p.m - 2 p.m
  • 2 p.m - 3 p.m
  • 3 p.m - 4 p.m
  • 4 p.m - 5 p.m
  • 5 p.m - 6 p.m
  • 6 p.m - 7 p.m
Preferred time slot
Field is required!
  • Preferred day
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
Preferred day
Field is required!
Reason for visit
Field is required!

Patient Reviews

Awesome company
Image is not available
Carina Barros

Awesome company and super friendly staff!

Very good team!
Image is not available
Breanna Thorn

I went to Stroud dental on monday for the first time in 13 years..... I was so afraid to go. The experience was amazing. They made me feel comfortable. Jess is very good at her job and gentle. I didnt feel embarrassed or shamed at all. They made sure I got my x Ray's up to date and informed me, my old x Ray's had baby teeth in them. Very good team! Happy I went in and faced my fears.

We highly recommend Stroud Dental!
Image is not available
Shawna Toole

My husband is terrified of going to the dentist and after convincing him to go to Stroud Dental for the first time he has now been 3 times! The staff is absolutely amazing and made him feel safe and comfortable! He actually looks forward to going to the dentist now. Dr. Peleg rocks and the girls are a hoot. We highly recommend Stroud Dental!

The best experience I have ever had!
Image is not available
Cassandra Dickson

Stroud dental was the best experience I have ever had! The staff are very knowledgeable and friendly, it was very clean, fast and efficient. thank you for making my smile beautiful! I would highly recommend this dental office.

A wonderful place to bring your children.
Image is not available
Logan Beau

Stroud Dental is a wonderful place to bring your children. The staff are amazing with my sons, one of which is on the autism spectrum. They are patient and understanding of his quirks. If you’re looking for a great place for dental work check out Stroud Dental.

We couldn’t be more happy.
Image is not available
Keith Shay Smeets

We have been patients of Stroud Dental for over five years!
They have the most amazing team, who make you feel comfortable, welcomed and part of their family!
They are so patient with our 15 month old daughter, and us!
We couldn’t be more happy with everyone at Stroud Dental!

Family, friendly!
Image is not available
Dana Donaldson

Family, friendly! Have always been great with my kids. Always a pleasant experience.

previous arrow
next arrow

Get In Touch With Us