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Dental Implant Consent Form Template

Streamline Your Patient Consent Process with Ease

When it comes to dental implants, your patients need to feel secure and informed about the procedure. This dental implant consent form template helps dentists like you facilitate clear communication and gain necessary permission from patients before treatment begins. Ensuring compliance with legal requirements, enhancing patient confidence, reducing liability risks, and providing a transparent experience are all benefits of this essential document. Try out the live template to see how it simplifies your workflow.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Primary phone number
Email address
Do you currently have any of the following medical conditions? (Select all that apply)
Are you currently under a physician's care?
Yes
No
List current medications and supplements (include dose if known)
Do you take blood thinners or anticoagulants (e.g., warfarin, apixaban, clopidogrel)?
Yes
No
Have you ever taken medications for bone density (e.g., Fosamax, Boniva, Actonel, Reclast) or denosumab (Prolia)?
Yes
No
Allergies or sensitivities (Select all that apply)
None
Local anesthetics
Antibiotics
Pain medications or NSAIDs
Latex
Metals
Acrylics
Adhesives
Other
Please Specify:
If other allergies or sensitivities, please list
Tobacco or nicotine use
Never
Former
Occasional
Daily
Vaping only
Prefer not to say
Alcohol or recreational drug use that may affect anesthesia or healing
Yes
No
Pregnancy or breastfeeding status
Not applicable
Pregnant
Possibly pregnant
Breastfeeding
Prefer not to say
History of radiation therapy to the head or neck
Yes
No
If yes, please provide details (site, date, complications)
Have you had dental implants, bone grafts, or implant complications before?
Yes
No
I have been informed of the nature and purpose of dental implant surgery and the proposed treatment plan.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I understand potential risks and complications (e.g., implant failure, infection, nerve injury, sinus issues, bleeding, swelling, bruising, pain, bone loss).
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I understand reasonable alternatives (no treatment, removable prosthesis, bridge) and that I may seek a second opinion.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I understand that outcomes cannot be guaranteed and that additional or staged procedures may be necessary.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I consent to the administration of anesthesia as recommended (local anesthesia, nitrous oxide, and/or oral/IV sedation as appropriate).
Yes
No
If sedation is used, I will arrange a responsible adult to accompany me to and from the appointment.
Yes
No
Not applicable
I authorize the dentist and clinical team to perform dental implant surgery and any additional procedures deemed necessary for my safety and optimal care.
Yes
No
I authorize necessary radiographs, CBCT scans, photographs, and impressions for diagnosis and treatment.
Yes
No
Permission for de-identified images or records to be used externally
Consent to educational use only
Consent to educational and marketing use
Do not consent to any external use
Preferred communication methods for care-related messages (Select all that apply)
Phone calls
Text messages/SMS
Email
Postal mail
I acknowledge I have received or been offered the Notice of Privacy Practices.
Yes
No
I understand I am responsible for charges not covered by insurance and that no guarantee of insurance benefits is made.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I agree to follow pre- and post-operative instructions and to contact the office if unexpected symptoms arise.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Are you at least 18 years old and legally able to consent?
Yes
No
By typing your full legal name below, you agree this serves as your electronic signature.
Date of signature
If you are not the patient, your relationship to the patient
Self
Parent/Legal guardian
Healthcare power of attorney/Agent
Other
Please Specify:
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Primary phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration showcasing a dental implant consent form concept for FormCreatorAI article.

When to use this form

Use this form before any implant placement to document informed consent for adults and for minors through a parent or guardian. It is essential for single-tooth replacements, immediate placements after extraction, full-arch cases, or when bone grafting or a sinus lift may be required. Clinics with multiple providers use it to standardize disclosures, capture medical history, and set clear expectations about anesthesia, risks, alternatives, and aftercare. For complex cases that include transfusion preparedness, pair it with a Blood transfusion consent form. To cover financial terms, communication preferences, and general office policies outside the procedure itself, use a Client consent form. The outcome: safer care, fewer misunderstandings, and complete records that protect your practice and support patient decisions.

Must Ask Dental Implant Consent Questions

  1. Do you understand the proposed implant treatment, its risks, benefits, and alternatives (including no treatment, a bridge, or a denture)?

    This confirms informed consent and sets realistic expectations about function, esthetics, time, and cost. It also reduces misunderstandings that lead to cancellations or complaints.

  2. Do you have any medical conditions, allergies, or medications (for example, blood thinners, bisphosphonates, or diabetes) that could affect surgery or healing?

    These details guide anesthesia choices, timing, and surgical approach to keep you safe. If your practice also offers facial injectables, capture that authorization with the Botox consent form.

  3. Do you consent to diagnostic imaging (X-rays/CBCT) and, if needed, bone grafting or a sinus lift to support the implant?

    Permission for imaging and adjunct procedures avoids delays during surgery and supports precise placement. It also documents your approval for clinically necessary steps if we discover insufficient bone.

  4. Do you agree to follow pre- and post-op instructions (smoking limits, hygiene, diet, medications) and attend all follow-up visits?

    Compliance is a top predictor of implant success and reduces complications like infection or implant loss. This question sets clear responsibilities and gives you a chance to ask for support or accommodations.

  5. Do you consent to the storage and use of your health information and clinical photos for charting, and optionally for education or marketing?

    Clarity about privacy and optional use builds trust and keeps your records lawful. General office permissions can be documented alongside this procedure using the Client consent form.

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