In order to fill Implant Removal Consent Form, the person must be above 18 years of age. The guardian or parent of a minor person will have to fill the form on his/her behalf.
Patient's Phone number
Emergency Contact number
I acknowledge that I have been informed of the risks, benefits, and alternatives to having my implant removed. I understand that there are risks involved with any surgical procedure, and I understand that no guarantees have been made to me regarding the results of this procedure. I hereby give my consent to my doctor to proceed with the removal of my implant.