6. I have been advised that smoking, alcohol or sugar consumption may affect tissue healing and may limit the success of the implant. Because there is no way to accurately predict the gum and the bone healing capabilities of each patient, I know I must follow my dentist's home care instructions and report to my dentist for regular examinations as instructed. I further understand that excellent home care, including brushing, flossing and the use of any other device recommended by my dentist, is critical to the success of my treatment and my failure to do what I am suppose to do at home will be, at a minimum, a partial cause of implant failure, should that occur. I understand that the more I smoke, the more likely is that my implant treatment will fail, and I understand and accept that risk.
7. I have also been advised that there is a risk that the implant may break, which may require additional procedures to repair or replace the broken implant.
8. I authorize my dentist to perform dental services for me, including implants and other related surgery such as bone augmentation. I agree to the type of anesthesia that he/she has discussed with me, circled below, and their potential side effects, specifically (local) (IV sedation) or (general). I agree not to operate a motor vehicle or hazardous device for at least twenty-four (24) hours or more until fully recovered from the effects of the anesthesia or drugs given for my care. My dentist has also discussed the various kinds and types of bone augmentation material, and I have authorized him/her to select the material which he/she believes to be the best choice for my implant treatment.
9. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in addition to or different from that now contemplated and I am under general anesthesia or I.V. sedation, I further authorize and direct my dentist, his/her associates or assistants of his/her choice, to do whatever he/she/they deem necessary and advisable under the circumstances, including the decision not to proceed with the implant procedure(s).
10. I approve any reasonable modifications in design, materials, or surgical procedures, if my dentist, in his/her professional judgment, decides it is in my best interest to do so.
11. To my knowledge, I have given an accurate report of my health history. I have also reported any past allergic or other reactions to drugs, food, insect bites, anesthetics, pollens, dust; blood diseases, gum or skin reactions, abnormal bleeding or any other condition relating to my physical or mental health or any problems experienced with any prior medical, dental or other health care treatment on my medical history questionnaire. I understand that certain mental and/or emotional disorders may contraindicate implant therapy and have therefore expressly circled YES or NO to indicate whether or not I have had any past treatment or therapy of any kind or type for any mental or emotional condition.