Patient Registration Forms for Dr. Mark De Simone 2023

Patient Information
Date of Appointment

MonthDayYear
Primary Dentist's Complete Name*
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
Patient Date of Birth*

MonthDayYear
Date
Patient Age*
Patient Weight*
Patient Height:*
Preferred Pharmacy Name*
Pharmacy Number*
Please enter a valid phone number.
Pharmacy Zip Code:*
Escort/Driver Name:*
Escort/Driver Phone Number:*
Please enter a valid phone number.
If completing this form on behalf of the patient, please indicate your relationship to the patient:
Following are questions regarding the PATIENT'S medical health/history. Your answers are for our records only and will be considered confidential. Please note that during your initial visit, you will be asked some questions about your responses to this questionnaire, and there may be additional questions concerning your health.

Please click on YES or NO (whichever applies), or fill in the blanks, where appropriate

	YES	NO
Are you in good health?
Has there been any change to your general health in the past year?
Are you currently under the care of a physician?

If yes, for what condition(s):
Your last physical examination was on:*

MonthDayYear
Date
The name and complete address of your physician is:

Have you ever (or are you currently):

	YES	NO
Had any serious illness, operation, or been hospitalized in the last 5 years?
Taken Aredia, Zometa, Fosamaz, Actonel, or Boniva?
Taking any medicine(s), including any non-prescription medicine(s)?

If yes, what medicine(s) are you currently taking:

Do you have, or have you had, any of the following diseases or problems?

	YES	NO
Damaged or artificial heart valves, heart murmur, or rheumatic heart disease
Cardiovascular disease, angina, heart attack, heart trouble, or stroke
Osteoporosis
Cancer requiring IV chemotherapy
Asthma or hay fever
Fainting spells or seizures
Diabetes
Hepatitis, jaundice, or liver disease
AIDS or HIV infection
Thyroid problems
Respiratory problems, bronchitis, etc.
Sleep apnea or snoring during sleep
Stomach ulcer or hyperacidity
Kidney trouble
High or low blood pressure
Sexually-transmitted disease
Epilepsy/other neurological disease
Problems with the spleen
Abnormal bleeding
Blood transfusion
Blood disorder, such as anemia
Treated for a tumor
Joint replacement (knee/hip)

Are you allergic, or have you had any reaction, to:

	YES	NO
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Iodine
Codeine or other narcotics
Other (if so, please list below)

If you are female:

	YES	NO
Are you pregnant?
Do you have any menstrual problems?
Are you nursing?
Are you taking birth control pills?

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold Dr. De Simone, my primary dentist, or any other member of their staff, responsible for any errors or omissions that I may have made in the completion of this form.
If your medical history is complex, or if you feel you would like to provide us with additional information, please use the space below to provide a chronological narrative of your medical history.
Signature of Patient (or Patient's Guardian)*

Clear
Date Signed:*

MonthDayYear
Date

Notice of Privacy Practices for Mark A. De Simone, DDS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Dental Practice Covered by this Notice--this Notice describes the privacy practices of Mark A. De Simone, DDS (“Dental Practice”). “We” and “our” means the Dental Practice. “You” and “your” means our patient.

II. How to Contact Us/Our Privacy Official--if you have any questions or would like further information about this Notice, you can contact Dr. De Simone at:
Phone: 972.978.3940 Fax: n/a
Email: mark@desimonedds.com Web: www.desimonedds.com

III. Our Promise to You and Our Legal Obligations--the privacy of your health information is important to us. We understand that your health information is personal, and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related healthcare services. We are required by law to:

• Maintain the privacy of your protected health information;
• Give you this Notice of our legal duties and privacy practices with respect to that information; and,
• Abide by the terms of our Notice that is currently in effect.

IV. Last Revision Date--this Notice was last revised on 1/1/2023.

V. How We May Use or Disclose Your Health Information--the following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes:

A. Common Uses and Disclosures

1. Treatment. We may use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, to physicians, or to other healthcare professionals involved in your care.

2. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you.

3. Healthcare Operations. We may use and disclose health information about you in connection with healthcare operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and healthcare professionals, quality assurance, financial or billing audits, legal matters, and business planning and development.

4. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, a letter, a phone call, a voice message, a text, or an email.

5. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or about health-related benefits and services that may be of interest to you.

6. Disclosure to Family Members and Friends. We may disclose your health information to a family member or a friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so.

7. Disclosure to Business Associates. We may disclose your protected health information to our third- party service providers (called “business associates”) that perform functions on our behalf or that provide us with services if the information is necessary for such functions or services. For example, we may use a business associate to assist us in maintaining our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

B. Less Common Uses and Disclosures

1. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA.

2. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury, or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and, notifying a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.

3. Victims of Abuse, Neglect, or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect, or domestic violence.

4. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the healthcare system, certain government benefit programs, and compliance with certain civil rights laws.

5. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify you or to obtain an order protecting the information requested.

6. Law Enforcement Purposes. We may disclose patient health information to a law enforcement official for law enforcement purposes, such as to identify or locate a suspect, a material witness, or a missing person or to alert law enforcement of a crime.

7. Coroners, Medical Examiners, and Funeral Directors. We may disclose patient health information to a coroner, a medical examiner, or a funeral director to allow them to carry out their duties.

8. Organ, Eye, and Tissue Donation. We may use or disclose patient health information to organ procurement organizations or to others that obtain, bank, or transplant cadaveric organs, eyes, or tissue for donation and transplant.

9. Research Purposes. We may use or disclose patient information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board.

10. Serious Threat to Health or Safety. We may use or disclose patient health information if we believe it is necessary to do so to prevent or to lessen a serious threat to anyone’s health or safety.

11. Specialized Government Functions. We may disclose patient health information to the military (domestic or foreign) about its members or veterans for national security and for protective services for the President or for other heads of state; to the government for security clearance reviews; and, to a jail or prison about its inmates.

12. Workers' Compensation. We may disclose patient health information to comply with workers' compensation laws or with similar programs that provide benefits for work-related injuries or illness.

VI. Your Written Authorization for Any Other Use or Disclosure of Your Health Information--uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.

VII. Your Rights with Respect to Your Health Information--you have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice.

A. Right to Access and Review--you may request to access and review a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.

B. Right to Amend--if you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete.

C. Right to Restrict Use and Disclosure--you may request that we restrict uses of your health information to carry out treatment, payment, or healthcare operations or to your family member or friend involved in your care or for the payment of your care. We may not (and are not required to) agree to your requested restrictions, with one exception: if you pay out of your pocket in full for a service you receive from us, and if you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request.

D. Right to Confidential Communications, Alternative Means, and Locations--you may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and if you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact or alternative address and indicate how payment for services will be handled.

E. Right to an Accounting of Disclosures--you have a right to receive an accounting of disclosures of your health information for the six (6) years prior to the date that the accounting is requested, except for disclosures to carry out treatment, payment, healthcare operations, and certain other exceptions as provided by HIPAA. The first accounting we provide in any 12-month period will be without charge to you. We may charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee, and you may choose to modify or withdraw your request at that time.

F. Right to a Paper Copy of this Notice--you have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official.

G. Right to Receive Notification of a Security Breach--we are required by law to notify you if the privacy or security of your health information has been breached. The notification will occur by first class mail within sixty (60) days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of your health information. The breach notification will contain the following information: 1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; 2) the steps you should take to protect yourself from potential harm resulting from the breach; and, (3) a brief description of what we are doing to investigate the breach, to mitigate losses, and to protect against further breaches.

VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic Information--certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact our office for more information about these protections.

IX. Our Right to Change Our Privacy Practices and This Notice--we reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, to the individual’s rights, to our legal duties, or to other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is 1/1/2023.

X. How to Make Privacy Complaints--if you have any complaints about your privacy rights or about how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.
Patient Acknowledgment: Receipt of Notice of Privacy Practices

I have read the above copy of Mark A. De Simone, DDS Notice of Privacy Practices effective 1/1/23.
Patient's Name: blanks*
I authorize the doctor and his/her staff to contact me by (check all that apply):

EmailPhoneMail
Signature of Patient

Clear
Date Signed

MonthDayYear
Date
Parent/Legal Guardian Acknowledgment: Receipt of Privacy Practices

I am a parent or legal guardian of blanks (patient's name) I have read the above copy of Mark A. De Simone, DDS' Notice of Privacy effective 1/1/23.

Parent or legal guardian's name:blank
Relationship to Patient:

ParentLegal Guardian
I authorize the doctor and his/her staff to contact me by (check all that apply):

EmailPhoneMail
Signature of Parent/Legal Guardian

Clear
Date Signed

MonthDayYear
Date

PRE-OPERATIVE INSTRUCTIONS FOR DENTAL SURGERY

** VERY IMPORTANT INFORMATION – PLEASE READ CAREFULLY **

1. We will be reviewing your medical history with you immediately prior to your procedure. Please be sure you are familiar with that information―especially with the name(s) and dosage(s) of any medications you are taking. If you feel your history is relatively complicated, we will need to decide if a consultation with your physician is necessary before the procedure is performed.
2. Unless specified by your dentist, all medicines taken on a routine basis should be continued without interruption. Please swallow with a minimal amount of water.
3. Patients who are minors (under 18 years of age) must have a legal guardian present to both fill out the “Medical History Update Form” and to sign the “Disclosure and Consent Form".
4. It is important to avoid smoking for at least one week before the surgery and one week following the surgery.
5. Keep in mind that it is best to allow for some flexibility around your appointment time on the day of your surgery. It is best not to "squeeze in" an appointment for surgery on an already busy day.

**IF you are having IV (intravenous) conscious sedation**:

1. Do not eat or drink anything (including water) for at least six hours prior to your appointment. Failure to do so may result in the canceling and future rescheduling of your appointment. If you are diabetic, please contact your dentist for more specific instructions.
2. A responsible adult, over 18 years of age, should accompany you to the office and should remain in the office during the entire procedure. Following the sedation, this responsible adult should be physically capable of assisting and accompanying you home and should remain with you for the next 24 hours. NOTE: Uber, Lyft, taxis, or other methods of public transportation are not acceptable.
3. For the first 24 hours following the sedation, you should refrain from the following: driving an automobile; operating heavy machinery; making legal decisions; drinking alcoholic beverages; or engaging in any activity that requires alertness.
4. There are important differences between general anesthesia (being completely asleep) and IV conscious sedation. If you have any questions about the IV conscious sedation process, please feel free to contact Dr. De Simone at 972.978.3940 prior to the procedure.

NOTE: If you have any concerns or questions about the surgery, please contact Dr. De Simone at 972.978.3940 or by email at mark@desimonedds.com.

I certify that I have read and understand the above. By signing below, I acknowledge that my questions, if any, have been answered to my satisfaction.
Patient Name*

First NameLast Name
Signature of Patient (or Patient's Guardian)*

Clear
Date Signed*

MonthDayYear
Date

DISCLOSURE & CONSENTS―DENTAL & ORAL SURGERY

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and about the recommended surgical, medical, or diagnostic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you can give or withhold your consent to the procedure.

I voluntarily request Mark A. De Simone, DDS and such associates, technical assistants, and other healthcare providers as they may deem necessary, to treat my condition which has been explained to me as:

Non-restorable, periodontally-involved, and/or impacted teeth___________________________________________

I(we) understand that the following surgical, medical, and/or diagnostic procedures are planned for me(us), and I(we) voluntarily consent and authorize these procedures under local anesthesia supplemental by: ____ Nitrous Oxide ____ IV Sedation ____ Oral Sedation

Surgical Extraction of Teeth_________________________________________________________________________

Dental Implants of Teeth____________________________________________________________________________

Bone Graft/Membrane of Teeth_____________________________________________________________________

I(we) understand that my doctor may discover other or different conditions which require additional or different procedures than those planned. I(we) authorize my doctor and such associates, technical assistants, and other healthcare providers to perform such other procedures which are advisable in their professional judgment.

I(we) understand that no warranty or guarantee has been made to me as to result or cure. I(we) have been given both oral and written post-operative instructions, and I(we) agree to personally contact Dr. De Simone in the event I(we) have a problem. I(we) will follow his instructions until that problem has been satisfactorily resolved. I(we) realize that in the event I(we) develop certain complications, I(we) may miss school or work schedules or I(we) may incur additional, unexpected expenses, including, but not limited to, expenses for other dentists, doctors, or medical facilities.

I(we) understand Dr. De Simone is not employed by my dentist but is an independent contractor and will receive a portion of the fee paid to my dentist for these services. I(we) have chosen Dr. De Simone from the alternatives I(we) have been offered to perform my dental surgery. I(we) understand that Dr. De Simone is a general dentist, and I(we) give Dr. De Simone and such associates permission to video or photograph procedure(s) for diagnostic and/or teaching purposes only.

Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me. I(we) realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, pain, swelling, bleeding, bruising, allergic reactions, cardiac arrest, brain injury, and even death. I(we) also realize that the following risks and hazards may occur in connection with this particular procedure.

A. Temporary or permanent nerve injury resulting in altered sensations or numbness of the lips, chin, tongue, teeth, and/or gums

B. Damage to adjacent teeth and/or dental restorations

C. Soreness at injection sites and/or along veins, as well as discoloration of the injection sites, bleeding, bruising, or swelling of the face and/or jaw

D. Opening of the sinus requiring additional treatment

E. Jaw fracture, muscle spasms, and/or limited opening of jaws for several days or weeks

F. Small root fragments remaining in the jaw due to an increased possibility of surgical complications

G. Jaw joint (TMJ) tenderness, soreness, pain, or locking, which may be temporary or permanent

H. Dry socket occurrence when a blood clot does not form properly, which can be extremely painful if not treated

I. Infection requiring additional procedures

J. Other_____________________________________________________________________________________
I(we) understand that IV conscious sedation (“twilight sleep”) and other forms of supplemental sedation involve additional risks and hazards, but I(we) request the use of IV conscious sedation and/or other forms of supplemental anesthesia to assist in the relief and protection from pain during the planned and additional procedures. I(we) realize the IV conscious sedation and/or other forms of supplemental anesthesia may have to be changed possibly without explanation to me(us). I(we) understand this is not general anesthesia (being completely asleep), and that it is unlikely, but I may have unpleasant memories of the procedure.

I(we) understand that certain complications may result from the use of any IV sedative or other form of anesthesia, including respiratory problems, drug reactions, paralysis, brain damage, or even death. Other risks and hazards which may result from the use of IV sedation or other sedatives or anesthetics range from minor discomfort to injury of the vocal cords, teeth, and/or eyes.

I(we) have been given an opportunity to ask questions about my(our) condition, alternative forms of anesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I(we) believe that I(we) have sufficient information to give this consent.

I(we) certify this form has been fully explained to me(us), that I(we) have read it or have had it read to me(us), that the blank spaces have been filled in, and that I(we) understand its contents.

INFORMATION FOR PATIENTS REGARDING POSSIBLE CHANGES
IN SENSATIONS OF THE LIP, CHIN, OR TONGUE
FOLLOWING DENTAL SURGERY

Dental surgery, like any other surgery, has certain inherent risks and limitations that may occur despite the experience and skill of the doctor. Following your surgery, it is possible that you may experience either temporary or permanent changes in the sensation or feelings of your lip, chin, or tongue. Permanent changes in sensation of the affected areas are extremely rare.

WHAT CAN CAUSE IT?
Because the nerves that supply these regions are close to the area where the surgery is performed, the nerves may not function normally for a while afterwards. These nerves affect sensation only and not movement.

The most common cause of this type of injury is from the pressure that can occur during either the removal of a tooth root or by the placement of an implant in the lower jaw. Occasionally, hooks or curves on the root may tear some of the nerve fibers. Another possible cause of injury is during the administration of the local anesthesia (numbing medicine). X-rays are helpful but cannot tell us the exact location of the important structures. When the nerve is especially close to the site of the surgery, it could be nicked or cut. Additionally, the incidence and severity of nerve injuries increases with age. This is particularly true for lower wisdom teeth. Further, sometimes sensation is affected without knowing exactly what caused it.

HOW LONG WILL IT LAST?

The likelihood that a change in sensation will occur and how long it will last can depend on many factors, including position of the tooth, the nerve, or the difficulty of the procedure. The duration of the condition is unpredictable and different in each case. It may last a few days, weeks, or months, and in very rare instances, may be permanent. In the majority of cases, the sensory loss gradually returns to normal although you may not be aware of any immediate improvement. Nerve tissue is the slowest tissue in the body to heal, and it can be weeks or months before you notice significant improvements. Nonetheless, it is important for you to stay in touch with us, so we may advise you of your specific circumstances.

HOW CAN I TELL IF I AM GETTING BETTER?

During nerve recovery, you may notice changes such as tingling, as if a local anesthetic is wearing off. Other sensations may also be present. Do not be alarmed; this is often a positive sign. It is important for you to help us in recording any changes in your symptoms so that we may better answer your questions and advise you as to your prognosis.

WHAT IF IT DOESN’T GET BETTER? CAN ANYTHING BE DONE?

If there has been absolutely no improvement in six weeks, then depending on your case, microsurgical repair could be considered. We can further council you on this possibility, and you will be referred to a specialist who is experienced and knowledgeable in this area.

Remember, in the overwhelming number of instances of altered sensation, all or most of the normal sensation will return. If residual symptoms do remain, the risks involved with surgical repair may not be warranted, in that spontaneous, post-operative recovery may take up to two years to occur. By keeping in close contact with us, we are better able to advise you throughout your recovery process to insure optimum results.

DENTAL IMPLANT CONSENT
(if applicable)

I have been fully informed of the nature of implants and implant surgery, therapeutic risks, and treatment alternatives to dental implants, and I hereby consent to their surgical placement in my jaws (mouth). I agree to maintain these implants as prescribed by my dentist.

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 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 IV conscious sedation (if requested by the patient or if deemed necessary). If a tooth is being extracted, there is no guarantee that an implant can be immediately placed. In that case, a graft will be placed, and the site will be re-evaluated after healing. In some cases, a temporary tooth can be immediately placed but only when quality bone is present. This temporary placement is for cosmetic purposes only and is not for chewing.

During the first two (2) weeks following the initial surgery, no dentures or partial dentures should be worn over the surgical sites without 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 imbedded 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.

Alternative Treatments to Implants

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 risk and benefits of alternative surgical procedures may be explained in greater detail by consulting an oral surgeon.

Risks

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; damage to adjacent teeth or root(s); bone loss; and, post-operative infection requiring additional treatment.

2. Prosthetic implant risks include, but are not limited to: 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 their removal and/or replacement.

No Warranty or Guarantee

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.

Consent to Unforeseen Surgical Conditions

During treatment, unknown oral conditions may modify or change the original treatment plan such as discovery of 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.

Patient Agreement to Daily Home Care

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 that once the implant is inserted, the entire treatment plan must be followed and completed on schedule. If the planned schedule is not carried out, the risk of implant failure increases.

I understand Dr. De Simone 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. De Simone of any problems that occur following the surgery. I understand how to get in touch with Dr. De Simone. 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 information consent to implant insertion and surgery and that all of my questions, if any, have been answered.

CONSENT FOR ALLOGRAFT TISSUE/BONE GRAFTING/
MEMBRANE PROCEDURES
(if applicable)

I(we) further understand that a separate procedure to obtain bone for grafting is intended and that portions of bone will be removed from my ________________________________________ and placed in the area to be treated.

I(we) understand that Dr. De Simone may discover other or different conditions which require additional or different procedures than those planned. I(we) authorize Dr. De Simone and such associates, technical assistants, and other healthcare providers to perform such other procedures which are advisable in their professional judgment.

I(we) understand that no warranty or guarantee has been made to me as to result or cure. I(we) have been given both oral and written pre- and post-operative instructions, and I(we) agree to personally contact Dr. De Simone in the event I(we) have a problem. I(we) will follow his instructions until that problem has been satisfactorily resolved. I(we) realize that in the event I(we) develop certain complications, I(we) may miss school or work schedules or I(we) may incur additional, unexpected expenses, including, but not limited to, expenses for other dentists, doctors, or medical facilities.

In addition to the risks of the primary surgical procedure, which have been explained to me(us) separately, I(we) understand that bone grafting itself involves specific risks. Dr. De Simone has explained to me(us) that such risks include, but are not limited to the following.

I. GENERAL RISKS AND COMPLICATIONS OF BONE GRAFTING:

A. Bleeding, swelling, infection, scarring, pain, nerve injury, sinus involvement, and numbness or altered sensation (possibly permanent) at the donor site, which may require further treatment
B. Allergic or other adverse reaction to the drugs used during or after the procedure
C. The need for additional or more extensive procedures in order to obtain sufficient bone
D. Rejection of bone particles from donor or recipient sites for some time after surgery
E. Rejection of the bone graft

II. RISKS AND COMPLICATIONS OF BONE GRAFTING FROM WITHIN THE MOUTH AREA:

A. Damage to adjacent teeth, which may require future root canal procedures or which may cause loss of those teeth
B. Removal of adult teeth in order to obtain sufficient bone material
C. Temporary or permanent numbness or pain in the area of the donor or recipient site or in more extensive areas
D. Penetration of the sinus or nasal cavities in the upper jaw, which could result in infection or in other complications, requiring additional drug or surgical treatment

III. RISKS AND COMPLICATIONS OF BONE GRAFTING FROM BANKED BONE (freeze-dried, lyophilized, demineralized, xenografts) OR BONE SUBSTITUTES:

On occasion, additional donated bone, processed bone, or artificial bone substitutes are used to supplement the patient’s bone or to spare patient an extensive graft harvesting procedure. If used, such materials may have separate risks, including, but not limited to:

A. Rejection of the donated or artificial graft material
B. The remote chance of viral or bacterial disease transmission from processed bone

IV. TYPES OF GRAFT MATERIAL: Some bone graft and membrane materials commonly used are derived from human or other mammalian sources. These grafts are thoroughly purified to be free of contaminants. Signing this consent signifies my approval for the doctor to use materials according to his or her knowledge and clinical judgment of my situation.

I(we) certify that: a) this form has been fully explained to me(us) and that its contents are understood; b) I(we) have read it or have had it read to me(us); c) the blank spaces were filled-in prior to initialing/signing; d) I(we) speak, read, and write English; and, e) I(we) have had my(our) questions answered. I have also been advised of the possible risks of non-treatment and understand that I have the option of seeking additional opinions from other providers, if desired.

I understand that I am to follow the oral and written instructions given to me, realizing failure to do so may result in less-than-optimal results of the procedure, and that I am to present myself for post-operative appointments, as scheduled.

I understand unforeseen circumstances may necessitate a change in the procedure, or, in rare cases, prevent completion of the planned procedure.

I authorize photographs, slides, X-rays, or any other visual records of my care and treatment during of after its completion to be used for the advancement of dentistry and reimbursement purposes. However, my identity will not be revealed to the general public without my permission.

I(we) have been given an opportunity to ask questions about: a) my condition; b) alternative forms of anesthesia and treatment; c) risks of non-treatment; d) the procedures to be used; and, e) the risks and hazards involved, and I(we) believe that I(we) have sufficient information to give this consent.

Patient Name*

First NameLast Name
Signature of Patient (or Patient's Guardian)

Clear
Date Signed

MonthDayYear
Date

**IMPORTANT—PLEASE READ!**
POST-OPERATIVE INSTRUCTIONS

DAY OF SURGERY--IMMEDIATELY FOLLOWING SURGERY:

Get Food—You should eat promptly following surgery. A drive-thru milkshake, protein shake, or smoothie usually works well for the drive home. Remove any gauze to eat or drink. Do not use a straw. You should eat liquid/mushy foods for up to 7 days following surgery (e.g., soup, broth, smoothies, mashed potatoes, pudding, yogurt, Jell-O, Ensure, ice cream, milkshakes, protein shakes, baby food, etc.). If you have to think about whether or not you should eat a food, make a different food choice.
Pick-up Prescriptions—Any prescriptions will be sent electronically to your pharmacy of choice. If for some reason you do not receive them, or if the pharmacy places them “on hold,” please reach out to Dr. De Simone directly.
Take Medications—Following your meal, you should start over-the-counter medications for pain control. Refer to your pain management card. If able, start with 600mgs of ibuprofen (Advil/Motrin). As illustrated on the card, other medications can be taken if pain is poorly controlled with ibuprofen alone, but ibuprofen is never skipped.
Control Bleeding—Keep your head elevated for several hours after surgery. Minimize talking. Do not suck or spit excessively. Place folded gauze over the extraction sites and maintain pressure by biting on the dressings for 20-30 minutes. Do not chew the gauze. Dressings should only be used if you are soaking them all the way through after each interval. If you are not saturating dressing all the way through after 20-30 minutes, simply remove them. Bleeding will be off-and-on the day of surgery. Overusing gauze to completely stop bleeding can actually cause further bleeding and a poorly-formed blood clot.

DAY AFTER SURGERY:

1. Begin oral hygiene again. Brush teeth gently/carefully. Avoid brushing or using Waterpik® on extraction site(s) until fully healed.
2. Begin rinsing your mouth 3 times per day with the prescription mouth rinse (or use 1 tsp. of salt in a glass of warm water). Swish gently for 1-2 minutes; let the rinse fall from your mouth into the sink. Avoid spitting. You may rinse more vigorously as each day passes. Transition to using the irrigation syringe provided 5 days after surgery.
3. Start your antibiotics, if prescribed. Take ALL that have been prescribed, AS DIRECTED.
4. You may resume most activities (drive a vehicle, return to work/school, exercise) based on comfort. Use caution if on prescription pain medication. No strenuous activity or heavy lifting for 7 days.

EXPECTATIONS:

1. Discomfort may occur for a few hours after the sensation returns to your mouth, gradually increasing for the first 3-4 days.
2. Swelling should increase for several days following surgery, and should reach its maximum in 3-4 days. You may ice (15-minutes on/15-minutes off) for the first 24-72 hours to help.
3. Bruising is normal.
4. Limited range of motion and restricted opening is common.
5. Discomfort and swelling should begin to diminish by the fifth post-operative day.
6. If sutures were used, they will dissolve on their own.
7. The extraction sockets will close and fill-in within 1-6 weeks following surgery. Upper sockets close and heal more quickly that lower ones.
8. You are expected to make a follow-up in 5-7 days to check healing and to receive further instructions (use of irrigation syringe) on how to keep the sockets clean.

CONTACT THE DOCTOR IF:

1. You are having trouble receiving your medications from the pharmacy.
2. Bleeding is excessive and cannot be controlled.
3. Discomfort is poorly controlled.
4. Swelling is excessive, spreading, or continuing to enlarge after 60 hours.
5. Allergic reactions to medications occur, which are causing a generalized rash or excessive itching

CONTACT EMERGENCY MEDICAL SERVICES (“EMS”) OR CALL “911” IF:
1. Patient has difficulty breathing.
2. Patient loses or has lost consciousness.
Patient Name*

First NameLast Name
Signature of Patient (or Patient's Guardian)*

Clear
Date Signed*

MonthDayYear
Date

Do’s & Don’ts

DO’s

1. Do eat a liquid/mushy meal promptly after surgery. Eat foods that you can swallow without chewing, and use a spoon.
2. Do eat 15 minutes prior to taking medications.
3. Do take all medications as prescribed (NO SKIPPING MEDICATIONS). For pain management, refer to the pain management card provided. Following your first meal after surgery, 600mg ibuprofen (Advil/Motrin) should be taken. The ibuprofen should be taken for 7 days, on-schedule, whether hurting, swollen, or not. Antibiotics and rinses should be started 24 hours after surgery. Anti-nausea and any prescription pain medications should be taken only as needed.
4. Do change gauze (if provided) every 20-30 minutes until bleeding slows. Gauze should only be needed for the first few hours.
5. Do expect your mouth to be numb for 6-12 hours after surgery.
6. Do use an ice pack (15 minutes on/15 minutes off) for the first 24-72 hours.
7. Do expect pain and swelling to peak on third or fourth day.
8. Do eat liquid/mushy foods for up to 7 days following surgery (e.g., soup, broth, smoothies, mashed potatoes, pudding, yogurt, Jell-O, Ensure, ice cream, milkshakes, protein shakes, baby food, etc.).
9. **Do return to the dental office within 5-7 days for post-operative appointment to check your healing (additional follow-ups may be requested, depending on the nature of your surgery).
10. Do call Dr. De Simone directly if things are not improving week-by-week (972.978.3940).

DON’Ts

1. Don't explore the surgical site, and keep your tongue, fingers, and food away from the surgical area.
2. Don't eat, drink, or sleep with gauze in your mouth.
3. Don’t chew the gauze.
4. Don’t spit for the first 24 hours.
5. Don't leave the patient alone for the first 24 hours.
6. Don’t eat foods that require you to chew for up to 7 days.
7. Don't use a straw for eating or drinking for 7 full days.
8. Don't smoke, dip, or drink alcohol for 7 full days.
9. Don't exercise hard or do any heavy lifting for 7 full days.
10. Don't blow your nose, hold in a sneeze, or blow into a musical instrument for 7 full days.

If there are any questions regarding the treatment or post-operative
instructions, please do not hesitate to call the office. We will
follow-up with you via phone on the day of treatment.
Patient Name*

First NameLast Name
Signature of Patient (or Patient's Guardian)*

Clear
Date Signed*

MonthDayYear
Date
** BE SURE TO CHECK DR. DE SIMONE'S WEBSITE **
FOR ADDITIONAL INFORMATION.

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