Implant Consent

I have been informed and afforded time to fully understand the purpose and the nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum and in the bone.

My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an implant to help secure the replaced missing teeth.

I consent to the extraction and the placement of the dental implant as well as a bone augmentation (bone graft), if necessary. 

I understand that if nothing is done, any of the following could occur: bone loss, gum tissue inflammation, infection, and sensitivity, possible tooth drifting, or looseness of teeth followed by the necessary extraction. Other possibilities include temporomandibular joint (jaw) problems. Headaches and referred pains to back of the neck and facial muscles, and tired muscles when chewing. In addition, I am aware that if nothing is done an inability to place implants at a later date due to changes in oral or medical conditions could exist.

I have further been informed of the possible complications and risk involved with surgery, drugs and anesthesia. Such complication includes pain, swelling, infection and discoloration. Numbness of the lip, tongue, skin cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are thrombophlebitis (inflammation of the veins), injury to teeth present, boned fracture, sinus penetration, delayed healing, allergic reaction to drugs or medication used etc.

My doctor has explained that there is no method to predict accurately the gum and bone healing capability in each patient following the placement of the implant.

I understand that certain postoperative events are to be expected including bleeding, bruising, swelling, limited function and pain. However, I also understand that there are unusual but rare complications and risks associated with this surgery including infection, nerve damage/numbness, sinus perforation, failure of treatment, esthetic expectations not being met and the necessity to re-operate.

It has been explained to me that implant surgery is a complex procedure and although a small percentage, implants can fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science: no guarantees or assurances as to the outcome of the results of the treatment or the surgery can be made. I am aware that there is a risk that the implant surgery may fail, which might require further corrective surgery or the removal of the implant with possible corrective surgery associated with the removal.

The timing of attaching the implant and prothesis, as well as the restoration of the dental implants hve been fully explained in detail.

I understand that the transitional/temporary prosthesis will remain in place during the healing period and any aesthetic changes will be done on the final prosthesis

I understand that excessive smoking: alcohol or blood sugar may effect gum healing and may limit the success of the implant. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.

I agree that I have been given the option for nitrous oxide or oral conscious sedation (seperate consent) and that I will be given local Aneasthetic.  

 

I request and authorize medical/dental services for myself, including implants and other surgery. I fully understand the contemplated procedure, surgery, or treatment conditions that may become apparent, which warrants, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modifications in design, material, or care, if it is felt it is for my best interest. If an unforeseen conditions arise in the course of the treatment which calls for the procedures  in addition to or different from that now contemplated, I further authorize and direct my doctor, associates or assistants, to do whatever they deem necessary and advisable under the circumstance, including the decision not to proceed with the implant procedure.

I agree to regular maintenance appointments with an FDC hygienist, beginning 3 months from the completion of my crown or denture. The ongoing maintenance frequency will be determined by my hygienist and will include an x-ray after 6 months and annually thereafter. I agree to follow the oral hygiene instructions that will be given to me.

I agree to notify my doctor’s office of any and all changes to my address and /or telephone number within a reasonable time frame (two to four weeks).

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

I consent to photography, filming, recording, x-rays and additional professional staff observing the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed.
 
l acknowledge that I have had the opportunity to ask questions and receive answers to and responsive explanations relative to the recommended and alternative treatments and procedures, and the risks and possible complications associated with these treatments prior to signing this form

I confirm that all the above had been discussed with me and I consent to the treatment