Removal of Dental Implant - Patient Information & Consent

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1.    I have been informed and I understand the purpose and the nature of the surgical procedure. I had all my questions answered by Perio Specialty Group (Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad) in a satisfactory manner.

2.    My doctor has carefully examined my mouth. Alternatives to this treatment have been explained.  

                                                                                   

3.    I have further been informed of the possible risks and complications involved with this surgery, drugs, and anesthesia. Such complications include pain, swelling, infection, discoloration, injury to the teeth present, jaw joint injury and risk of jaw fracture during the surgery. In case of jaw fracture during surgery hospitalization and further treatment will be required.

 

4.    I understand that the removal of the existing implants might results in significant amount of bone loss that could weaken the jaw bone resulting in jaw fracture in the future. Furthermore, I am aware that following the appropriate healing period, I might not have adequate amount of bone for future implant placement in the same region.  

 

5.    I am aware that this surgery could result in more damage to the nerve below the teeth/implants making the prognosis for any nerve recovery, if at all, less favorable. Also possible are inflammation of a vein, injury to teeth present, bone fractures, sinus penetration (for upper jaw), delayed healing, allergic reactions to drugs or medications used, etc. I also understand that my body may react adversely to the stress of a surgical procedure, with cardiac arrest being the most serious, but remote, possibility.

 

6.    I consent to the administration of anesthetics or sedative drugs if prescribed and agree not to operate a motor vehicle or hazardous device for at least 24 hours after their administration.

 

 

7.    My doctor has explained that there is no method to accurately predict the gum and the bone healing capabilities in each patient following these kinds of surgeries. This includes also the gum tissue and the bone around the neighboring teeth. 

Removal of Dental Implant - Patient Information & Cosent

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8.I also understand and agree that I must return for appropriate post-operative care and evaluation, as outlined by my doctor. I understand that I must return for follow-up care at an interval determined by Perio Specialty Group (Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad) for evaluation of the surgical site, a review of oral hygiene and for plaque removal. A fee will be charged for this service.

9. I understand that smoking and alcohol may affect the healing and the success of the surgery. I agree to follow my doctor's home care instructions. I agree to report to my doctor for regular examinations and radiographs as instructed.

10. To my knowledge I have given an accurate report of my physical and mental health history. I have reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, and also reported any blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.

11. I had the opportunity to read this form, ask questions, and have my questions answered to my satisfaction. I hereby consent and request that my doctor proceeds with the surgical procedure removing my implant(s I also understand that following the contemplated procedure, surgery or treatment, unforeseen circumstances may necessitate a change in the desired procedure or in the rare cases, prevent completion of the planned procedure.

12. I hereby state that I read, speak and understand English.