I understand that Dr. _____________________ will give his best professional care toward accomplishment of the desired results. I understand that I can ask for recital of all possible risks attendant to phases of my care at any time. I have discussed this consent form with Dr. _____________________ and I further understand that I am free to withdraw from treatment at any time. I also give permission for persons other than the doctors involved on my care and treatment to observe this operation and I consent to photography, filming, recording and x-rays of the procedure to be performed for the purposes of teaching and research, provided my identity is not revealed. I understand this consent form and I request Dr. _____________________ to perform the surgery discussed. I CERTIFY THAT I HAVE HAD AN OPPRORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE CONSENT AND THE EXPLANATIONS REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY WERE STRICKEN BEFORE I SIGNED. I ALSO STATE I READ AND WRITE ENGLISH. Dentist Signature                                   Patient Signature Witness Signature                                 Witness Signature Parent or Guardian, if Patient is a Minor Date: To Consent Library