is critical for the ultimate success of dental implants. I accept responsibility for any adverse consequences which result from not following my dentist's advice. 15. Questions I have to ask my dentist: _______________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 16. 1 CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE AUTHORIZATION AND INFORMED CONSENT TO IMPLANT PLACEMENT AND SURGERY AND THAT ALL MY QUESTIONS, IF ANY, HAVE BEEN FULLY ANSWERED. I HAVE HAD THE OPPORTUNITY TO TAKE THIS FORM HOME AND REVIEW IT BEFORE SIGNING IT. I UNDERSTAND AND AGREE THAT MY INITIAL ON EACH PAGE ALONG WITH MY SIGNATURE BELOW WILL BE CONSIDERED CONCLUSIVE PROOF THAT I HAVE READ AND UNDERSTAND EVERYTHING CONTAINED IN THIS DOCUMENT AND I HAVE GIVEN MY CONSENT TO PROCEED WITH IMPLANT TREATMENT AND RELATED SURGERY, INCLUDING ANY ANCILLARY BONE GRAFTING PROCEDURES Dentist Signature                                   Patient Signature Witness Signature                                 Witness Signature Parent or Guardian, if Patient is a Minor Date: To Consent Library