office or hospital for my care. I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me home after my discharge from surgery. I agree to cooperate completely with the recommendations of Dr._____________________ while I am under his care, realizing that any lack of same could result in a less than optimum result. I have had an opportunity to discuss with Dr. _____________________ my past medical and health history including any serious problems and/or injuries. I understand that certain anesthetic risks, which could involve serious bodily injury, are inherent in any procedure that requires a general anesthetic. The fee for services has been explained to me and is satisfactory, and I understand there is no warranty or guarantee as to the result and/or cure and that my condition may return or worsen. I consent to photography, filming, recording and x-rays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed. I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATION 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