The initial surgical phase consists of the surgical reflection of the gum tissue followed by precision drilling of holes into the underlying jawbone which depth and width are somewhat smaller than the roots of your natural teeth. These holes are immediately filled with metal cylindrical posts (implants), which are designed to remain in the jawbone indefinitely. In some situations, where the inadequate bone is present, a regenerative procedure might be utilized in which a freeze-dried bone graft is placed and the site is then covered with a regenerative membrane. All surgery is performed under local anesthesia and may be supplemented with sedative drugs or I.V.

Conscious Sedation (if requested by the patient or if deemed necessary).
During the first two (2) weeks following the initial surgery, no dentures or partial dentures should be worn over the surgical sites without the consent of the surgeon.
The second surgical procedure usually occurs three-to-eight months after the initial surgery. At this time the implant is evaluated for proper healing and a post is placed into the implant, which extends through the gum tissue into your mouth. Additionally, a minor surgical correction of tissue may later be necessary to modify any tissue overgrowths or discrepancies.

In the final prosthetic phase, a metal sleeve is threaded into the previously surgically embedded implant, which is then attached (anchored) to the overlying denture, crown, or bridge. The fee for the prosthetic phase is separate and not part of the surgical fee.

1. If no treatment is elected to replace existing dentures or missing teeth, the non-treatment risk includes maintenance of the existing full or partial denture with relines or remakes every three-to-five years for shifting of teeth, or as otherwise may be necessary due to the slow but progressive resorption (dissolution) of the underlying (supporting) jawbone.
2. Construction of new full or partial dentures or bridges, which may provide better fit and function than your present situation.
3. Surgical treatment to provide a better base or foundation for a new denture. Associated risks and benefits of alternative surgical procedures may be explained in greater detail by consulting an oral surgeon.

1. Surgical risks include, but are not limited to: post-surgical infection; bleeding; swelling; pain; facial discoloration; sinus or nasal perforation during surgery; TMJ Jaw joint) injuries or spasms; bone fractures; slow healing; and, transient, but on occasion, permanent numbness of the lip, chin, and tongue.
2. Prosthetic implant risks include, but are not limited to: the unsuccessful union of the implant to the jawbone and/or stress metal fractures of the implant. After one ( 1) year of stable implant retention, it is probable that the implant is permanently joined to the underlying jawbone. A separate surgical procedure for removal of the implant is necessary if implant failure or fracture occurs or requires replacement for changed prosthetic needs. If the implant fails, there will be fees charged for its removal and/or replacement.
3. If a crown is placed on the implant, it can decement or/and get loose anytime. If it occurs 3 years after its placement, the fee to re-tighten or re-cement is estimated to be $175. This fee might not be covered by your dental insurance plan. It will be paid at the time of service.
4. If an abutment is placed on the implant to hold a denture, it can get loose anytime in the future. If it occurs 3 years after its placement, the fee to reinsert or tighten the abutment is estimated to be $175.

I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed implant will be completely successful in function or appearance (to my complete satisfaction). It is anticipated that the implant will be permanently retained, but because of the uniqueness of every case, and since the practice of dentistry is not an exact science, long-term success cannot be promised.

During treatment, unknown oral conditions may modify or change the original treatment plan such as the discovery of a changed prognosis for adjacent teeth or insufficient bone support for the implant. I, therefore, consent to the performance of such additional or alternative procedures as may be required by proper dental care in the best judgment of the treating doctor. 

I understand that smoking, alcohol, and improper dietary practices may affect gum and bone healing and will limit the success of the implant. I agree to follow home care and dietary instructions as prescribed.

In order to improve chances for success, I have been informed that the implant and adjacent teeth must be maintained daily in a clean and hygienic manner, and I agree to perform the home care in accordance with instructions provided, as well as keep periodic professional maintenance visits.

I understand Dr. Carpentier is a general dentist, and that he will be responsible to assist me during the post-operative phase. It is my responsibility to inform Dr. Carpentier of any problems that occur following the surgery. I understand how to get in contact with Dr. Carpentier. In rare cases, it may be necessary to refer some post-operative patients to another doctor. The costs associated with any consultation or treatment with other doctors will be the patient's responsibility.

I certify that I have read and fully understand the above authorization and informed consent to implant insertion and surgery and that all of my questions, if any, have been answered.

My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as "bleaching") of my teeth. This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure.

Zoom-in-office tooth whitening is a procedure designed to lighten the color of my teeth, that uses using a combination of a hydrogen peroxide gel and a specially designed visible LED light lamp. The Zoom treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the Zoom lamp for four (4) 15-minute sessions. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open, while the soft tissues of my mouth (i.e., my lips, gums, cheeks, and tongue) will be covered to ensure they are not exposed to either the gel or light. I will be provided a visible LED light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

I understand I may decide not to have the Zoom treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include Whitening Toothpastes/Gels, Other In-office Whitening Treatments, Take-Home Whitening Kits, Porcelain Crowns, Veneers, or Composites.

I understand that the cost of my Zoom treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my Zoom treatment.

I understand that:

• Existing issues should be treated before undergoing a whitening procedure.
• Results will vary or regress due to a variety of circumstances.
• Zoom whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite, or other restorative materials. These types of restorations may need to be replaced at my expense to match my newly whitening teeth.
• Darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth.
• Teeth with multiple colorations, bands, splotches, or spots due to tetracycline use or fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all.
• Previous orthodontic treatments may cause teeth to whiten unevenly if any resin from the treatment was not properly removed from the teeth, either due to residual resin remaining on the teeth or overpolishing upon removal.
• Those with porcelain fused to metal crowns, amalgams, lingual bars or implants may feel excessive heat.
• Teeth with many fillings or cavities may not lighten and are usually best treated with other non­whitening alternatives.
• The Zoom Lamp emits visible LED light and all materials used in the isolation process, when properly used as directed, will block any exposures of soft tissues to this light.
• It is recommended that those currently treated for a serious illness or disorder (e.g. immune-compromised, AIDS, etc) should consult a medical doctor before use.
• Zoom treatment is not recommended for pregnant or lactating women.

I understand that the results of my Zoom Treatment cannot be guaranteed.

I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the Zoom whitening system, the treatment is not without risk.

I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity/Pain - During the first 24 hours after Zoom treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a Zoom treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession exposing root surfaces, exposed dentin, untreated caries, cracked teeth, abfractions, oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher penetration of the gel into the tooth may find that those condition increase or prolong tooth sensitivity or pain after Zoom treatment. 

Gum/Lip/Cheek Inflammation/Burn - Improper isolation during the whitening procedure may cause or result in (i) inflammation of your gums, lips, or cheek margins due to exposure of a small area of those tissues to the whitening gel or the LED light, or (ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is usually temporary and will subside in a few days. Although, this persists longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or LED light. 

Dry/Chapped Lips - The Zoom treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor that covers the lips. This could result in dryness or chapping of the lips or cheek margins, which can be treated by the application of lip balm, petroleum jelly, or Vitamin E oil. 

 

Cavities or Leaking Fillings - Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing the gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the Zoom treatment. 

Cervical Abrasion/Erosion - These are conditions that affect the roots of the teeth when the gums recede. They are characterized by grooves, notches, and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/ erosion exists on my teeth, these areas will be covered with a dental dam prior to my Zoom treatment. 

Relapse - After the Zoom treatment, it is natural for the teeth that underwent the Zoom treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take-home tray or repeating the Zoom treatment. I understand that the results of the Zoom treatment are not intended to be permanent and that secondary, repeat or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth. 

The safety, efficacy, potential complications, and risks of Zoom treatment can be explained to me by my dentist and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of Zoom treatment, the list of complications in this form is incomplete.

The basic procedures of Zoom treatment and the advantages and disadvantages, risks, and known possible complications of alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction.

 

I understand that there is no way we can guarantee anything which goes into the mouth and which is under the control of the individual patient. Physicians do not tell you that the transplanted heart, kidney or coronary bypass will keep you alive for any specified period. We can only tell you that we will strive to do the dentures properly, provide you with the information you need to help care for your dentures and we will be available for regular periodic follow-up appointments to evaluate your continued dental health. Also, you must return to our office at regular intervals for examination and service according to our recommendations. This will represent an extra cost to you, the patient. 

We recommend the day of surgery plus the following day or two to be off for recovery. You can expect to have some swelling, pain (discomfort), and possibly some bruising. The time taken off from work is really an individual decision.

Because the dentures are done before pulling the teeth, I understand it is impossible to try them to see how they fit in my mouth. They might need more adjustments on the day of the insertion and later. In consequence, the bite, contour, shape, shade, function, position, and aesthetic might not be adequate at all. They might not be comfortable at all to wear during the healing period which could take up to six months.

I will probably need permanent to reline(s) done usually six to nine months after the extractions at an additional charge.

I understand it is possible that I will need totally new dentures after the healing period of six months and that will represent an additional fee to me. The fee is the same as getting new dentures.

I understand that between the day of insertion of the denture(s) and three months
later, adjustments are included in the original cost. However, it is possible that I will
need temporary reline every four to six weeks at an additional cost per denture every time.

I understand that after a three-month period, I will have to pay per visit to get my
dentures adjusted.

I understand I might have a hard time getting used to my dentures to talk, eat, or to simply keep them in my mouth. I understand that some people do not get used to them and that I might be one of them.

I understand that dentures do not stop bone resorption and that my denture(s) will get looser over time.

I understand any modifications in design or materials if it is in my best interest.

I understand that I would get a better fit for my denture(s) if I wait approximately 12 weeks after the extractions before getting them done. I understand the disadvantages of not waiting.

I understand that dentures are done in acrylic and can break. The repairs will be charged after the delivery date. It is my responsibility to pay for any repairs required.

I understand that there is no way we can guarantee anything which goes into the mouth and which is under the control of the individual patient. Physicians do not tell you that the transplanted heart, kidney, or coronary bypass will keep you alive for any specified period. We can only tell you that we will strive to do the dentures properly, provide you with the information you need to help care for your dentures and we will be available for regular periodic follow-up appointments to evaluate your continued dental/mouth health. Also, you must return to our office at regular intervals for examination and service according to our recommendations. This will represent an extra cost to you, the patient. 

I understand that between the day of insertion of the denture(s) and three months later, adjustments are included in the original cost.

I understand that after a three-month period, I must pay per visit to get my dentures adjusted.

I understand that I might have a hard time getting used to the new dentures to talk, eat, or just to keep them in my mouth. I know it will take at least two to three weeks to get used to and that I will need to come in for adjustments. And it may take several times.

I understand that dentures do not stop bone resorption and that my denture(s) will get looser over time.

I approve any modifications in design, materials, or care if it is felt for my best interest.

I understand that dentures are done in acrylic and can break. The repairs are not charged in the first 3 months after the delivery. It is my responsibility to pay for any repairs after 3 months.

 

I accept and understand that endodontic therapy is an attempt to save a tooth or teeth that might otherwise require extraction. I also accept and understand that endodontic therapy is used to correct an apparent problem and occasionally undiagnosed and/or hidden problems arise.

I have been fully informed that endodontic therapy is not always successful as the tooth or teeth is/are already in jeopardy.

I accept and understand that this endodontic therapy will not prevent future decay and/or possible fracture. I also accept and understand that endodontic therapy may not prevent future problems with the tooth or teeth, as the tooth or teeth will be more brittle.

The endodontic therapy has been fully explained to me, including all risks and complications involved. I have been fully informed that the risks and complications may include, but are not exclusive of:

• Perforation of the canal with instruments could result in the loss of the tooth and perhaps surgery.
• Nerve or sinus damage causing temporary or permanent numbness of the chin, tongue, or lips.
• Instrument breakage in the canal may require surgery.
• Minor pain.
• Swelling.
• Temporary or permanent numbness.
• The need for additional treatment, surgery, and/or extraction.
• The need for additional procedures on the tooth or teeth, such as post and crown(s).
• Loss of the tooth or teeth.
• I have been fully informed that the condition of the tooth or teeth will worsen and that other systemic problems could develop if the procedure is not done.

I accept and understand there is NO WARRANTY or GUARANTEE as to any result and/or cure.

I have had the opportunity to discuss endodontic therapy, and have had an opportunity to ask questions, and am fully satisfied with the answers received.

If during the endodontic therapy, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.

The purpose of this Informed Consent Form is to provide an opportunity for patients (and/or their parents or guardians) to understand and give permission for elective dental treatment. Each item should be initialed after the patients (and/or their parents or guardian) have the opportunity for discussion and questions.

I accept and understand that the procedure(s) is/are elective in na1ure and not a treatment for any dental disease.

I accept and understand that although Dr. Racicot will make every effort to repair my denture/partial to my desires, there are limitations due to function, color, the extent of inherent staining, shape, and/or placement of the original teeth.

I accept and understand that denture (partial or full) treatment results are subjective; thus, the outcome of my Treatment Plan may not completely meet my expectations.

I accept and understand that the alternatives to the Treatment Plan, which have been fully discussed with me, include but are not exclusive of:

• A new denture or partial
• Dental implants, endodontic therapy, crowns, bridges
• No Treatment.

Each option has been fully explained to me with its' benefits, risks, pros, com, and approximate investment cost. I accept and understand that there are risks and limitations to all procedures. For this denture or partial repair, these risks and limitations include, but are not exclusive of:

• Looseness of denture {partial or full)
• Soreness of gum tissues
• Shrinkage (mild to severe) of gum tissues
• Breakage of denture {partial or full)
• Reline, readjust or replace denture {partial or full) - (at additional costs)
• Change in speech or appearance
• Difficulty wearing dentures (partial or full)

I have had the opportunity to discuss the Treatment Plan, and have had an opportunity to ask questions, and am fully satisfied with the answers received.

I accept and understand that, as with any medical or dental procedure, there are no guarantees as to the longevity of the work performed. I also accept and understand that the Treatment Plan does not contain any warranty and that any future adjustment(s) or replacement(s) will be at additional cost(s).

 

I accept and understand that, if these conditions are complied with, the ONLY WARRANTY provided under the Treatment Plan is:

• THIRTY (30) DAYS - all adjustments following the denture or partial repair will be at no charge (this does not include denture replacement).
• AFTER THIRTY (30) DAYS - patient pays 100% of the current fee.

I have been advised to have {wisdomTooth65} wisdom teeth removed. I have been informed of the risks and post-surgical complications of wisdom tooth surgery by the doctor, which are but not limited to; pain, bleeding, bruising, swelling, stiffness of the jaw joints, infection, and injury to the nerves of the lower jaw which could result in numbness or loss of feeling to the lips, teeth, cheek, and tongue. The doctor has also explained the necessity of surgery and alternatives to treatment.