IMPLANTSCONSENTFORMsteinwayfamilydentalcenter

PATIENT NAME:
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I hereby authorize my doctor(s) and staff to perform the following procedures:
_____________________________________________________________________________________
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I understand the doctor may discover other conditions that may require additional procedures. I
authorize him to perform such other procedures, as he deems necessary in his professional
judgment in order to complete my treatment.
I have read and discussed the procedure with Dr. Terranova and believe I have been given
sufficient information to give my consent to the planned surgery.
Patient’s (or legal guardians’ signature)
Date
Witness’ Signature
Date
Doctor’s Signature
Date
Albert Malakov, DDS
Aleksandr Dayanayev, DDS
Victor Terranova, DMD, MS, Ph. D