RCT Consent V2


I, Crystal Wall, have been informed and understand that dental implants are available to certain dental patients. These dental implants are titanium alloy dental implant screws that are placed in a patient’s jaw to provide immediate and on-going stabilisation of my denture. I understand that the alloy contains titanium, aluminium and vanadium. I am aware that these implants are being used to retain a superstructure made of a titanium bar with a metal and acrylic denture attached to it.

I wish to undergo this procedure as a patient of Dr Trilok Rao Vallury and I have requested one of more dental implants to be placed into my jaw. Dr Trilok Rao Vallury has given me the option of a specialist referral for this procedure. Dr Trilok Rao Vallury has also advised me about the possibility procedure being done under GA. I have opted to have this done in the chair. Dr Trilok Rao Vallury has advised me that the implants will be placed by a guided procedure and that we might place three to six (3-6) implants a the time of the surgery.

I understand that in the event any of the 6 dental implants implanted by Dr Trilok Rao Vallury  fail, they may be removed through a subsequent surgical procedure. I further understand that it is possible that one or more of the implants may fail during the healing process. Dr Trilok Rao Vallury has advised me that as long as there are four (4) strategic implants we can still maintain the superstructure. It has also been explained to me that once the implants are inserted a recommended program of personal oral hygiene must be strictly followed by me and completed on schedule. I am aware that I must return for appropriate post-operative care and evaluation on a timely basis which will include evaluation of oral hygiene, X-rays removal or the bar and plaque removal. I have been informed that if this schedule and plan are not carried out, the implants may fail in the long run. I have also been informed about all surgical complications including the possibility of sinus involvement in the upper jaw. I have also been advised about the possibility of nerve damage caused due to the placement of implants in the lower jaw. Dr Trilok Rao Vallury has explained shown me a simulation of the end result and I am happy with the aesthetics. I have also been advised about a denture flange being present below my upper lip which can cause a bit of fullness. The possibility of alternative procedures for my individual need have been discussed and an offer made to answer any questions with regard to those procedures.

I also understand that function and comfort will be the primary goals of this dental procedure, but that the success rates of each patient vary. I have also been informed that gum disease, use of tobacco, including cigarette smoking and excessive alcohol consumption, can cause the failure of dental implants.

I have further been advised that swelling, infection, bruising ,bleeding and/or pain may be associated with any surgical procedure.

I have provided my full medical history and have provided a list of all current medication.

Dr Trilok Rao Vallury has discussed all the medical conditions which can effect the long term success of the implants. He has advised me that in the future medications for Osteoporosis can lead to a failure of an integrated implant.

Please initial at the end of each bullet point

Having been fully informed of the above, I hereby knowingly consent to the recommended surgical procedures outlined to me by Dr Trilok Rao Vallury and request him to place one or more dental implants in my jaw for the purpose of dental reconstruction and function enhancement.


I further state that I have carefully read this surgical consent form and understand the contents.