Hanson Consent for Dental Implants

Patient's Name*

First NameMiddle NameLast Name

Birth Date*

MonthDayYear

Responsible Party*

SelfParent/Guardian

Responsible Party's Name*

First NameMiddle NameLast Name

Patient's Email*

Confirmation Emailexample@example.com

I hereby give consent to * to perform Dental Implant
procedure(s) on me or my dependent and any such additional procedure(s) as may be considered necessary for my well-being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the recommended treatment.

Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-operative pain, bleeding, oozing, infection and/or bone infection. Bruising
and/or swelling, delayed healing, restricted mouth opening for several days or weeks.
3. Damage to adjacent teeth or tooth restorations.
4. Possible involvement of the sinus cavity and creation of an opening from the
mouth into the nasal or sinus cavity, which may require additional treatment or
surgical repair at a later date.
5. Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia, resulting in altered or loss sensation, numbness, pain, or
altered feeling in the face, cheek(s), lips, chin, teeth, gums, and/or tongue
(including loss of taste). Such conditions may resolve over time, but in some
cases, may be permanent.
6. Inability to place the implant due to the local anatomy or implant failure.
7. Discoloration and appearance changes of the gum tissue or unsatisfactory
cosmetic result.
8. Bone loss around the implant(s) and/or adjacent teeth, which may result in loss
of implant and/or adjacent teeth and which may necessitate bone grafting
9. Jaw fracture.
10. As a result of the injection or use of anesthesia, at times there may be swelling,
jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth,
jaws and/or facial tissues, which is typically temporary, but in rare instances, may
be permanent.

Patient's Signature*

Clear

Patient's Name

First NameMiddle NameLast Name

Responsible Party's Signature*

Clear

Responsible Party's Name

First NameMiddle NameLast Name

Date

Hour MinutesAM/PM Option

Recommended Treatment

Treatment Alternatives

Risks and Complications