| ADDRESS: 805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6 TEL: 613-389-8660 EMAIL: reception@davidgouettdentistry.com
# Implant Information and Consent Form Official Clinical Data Record Submission
Patient Name: | [Patient Name Response]
Implant Type: | [Implant Type Response]
1. | I have been informed of the nature of my dental condition and the nature of the proposed implant surgical procedure. My dentist has explained to me the available alternative methods of treatment and their advantages and disadvantages.
2. | I understand that there are potential risks and complications associated with any surgical procedure. These include, but are not limited to: post-operative pain and swelling, bleeding, bruising, infection, temporary or permanent numbness of the lip, chin, tongue or cheek, and sinus complications.
3. | I understand that smoking and/or alcohol consumption can significantly decrease the success rate of the implant procedure and may lead to implant failure.
4. | I consent to the administration of such anesthetics as may be considered necessary or advisable by the dentist for this procedure.
5. | I have provided an accurate and complete medical and dental history, including all medications I am currently taking, both prescription and non-prescription.
6. | I understand that dental implants are not guaranteed and that no promise has been made to me as to the results of the surgery or the longevity of the implant.
7. | I understand that once the implant is placed, it is my responsibility to maintain excellent oral hygiene and to attend regular follow-up appointments as recommended by my dentist.
8. | I consent to the taking of photographs or other audiovisual records of my dental treatment for clinical and educational purposes.
9. | I authorize Dr. David Gouett and his associates to perform the implant surgical procedure as described to me. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.
ATTENDING DENTIST Dr. David Gouett |  | SIGNATURE OF PATIENT/GUARDIAN [Digitally Endorsed by Patient]
WITNESS [Digitally Endorsed by Witness] |  | DATE [mm/dd/yyyy]
© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.