Forms

Apart from the PRE-ANESTHESIA QUESTIONNAIRE and the MEDICAL QUESTIONNAIRE the forms are read only. Please read them and submit. All forms will be signed in office on the day of treatment.

Implant Informed Consent

IMPLANT SURGERY

INFORMATION AND CONSENT FORM

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

2) My doctor has carefully examined my mouth and explained alternatives to this treatment have been explained to me. I have either tried or have considered these options and have concluded that an implant is my treatment of choice to secure the tooth or denture to be replaced.

3) I have further been informed of the possible risks and complications involved with surgery, drugs (allergic or adverse reactions) and anesthesia. Such complications include pain, swelling, infection, bruising. Numbness of the lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Other possible risks are injury to other teeth, bone fractures, sinus perforation, delayed healing, rejection of the implant.

4) It has been explained to me that in some instances implants fail and must be removed. The success rate of dental implant surgery is very high but dentistry is not an exact science and no guarantee or assurance as to the outcome of the result of treatment can be made.

5) I understand that if nothing is done any of the following could occur: loss of bone and/or gum tissue, inflammation of the gums, infection, loose teeth, loss of teeth, and the occurrence or reoccurrence of Temporomandibular (jaw) joint symptoms

6) I understand that excessive smoking, alcohol, or sugar may affect healing and may limit the success of the implant. I agree to follow my doctors home care instructions. I agree to report to my doctor for regular examinations as instructed.

7) To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, reported any bleeding disorders or any other condition related to my health

8) I consent to the photographing filming videotaping of the procedure to be performed provided my identity is not revealed.

9) I request and authorize the dental services for me, including implants and other surgical procedures as deemed necessary to accomplish the placement of the implants. I fully understand that during and following the procedure conditions may become apparent that warrant additional or alternative treatments pertinent o the success of the comprehensive treatment. I also approve any modification in the design or materials if it is felt to be in my best interest.

10) The fees for this treatment plan and the payment plan have been explained to me and I have approved them.

Narcotic Strategy

Ontario’s Narcotics Strategy

List Of Approved Forms Of Identification

  • Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.
  • Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.

The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.

Below is a list of forms of identification that a person can present to a prescriber or dispenser:

  • Ontario Health Card or other health card issued by a Province or Territory in Canada
  • Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)
  • Ontario Photo Card
  • Birth Certificate from a Canadian province or territory
  • Government-issued Employee Identification Card
  • Ontario Outdoors Card
  • BYID (age of majority card)
  • Certificate of Indian Status
  • Valid Passport – Canadian or other country
  • Certificate of Canadian Citizenship
  • Canadian Immigration Identification Card
  • Permanent Resident Card
  • Old Age Security Identification Card
  • Canadian Armed Forces Identification Card
  • Royal Canadian Mounted Police/Provincial/Municipal Police Identification
  • Firearms Possession and Acquisition Licence

Post Operative Instructions

POST OP FOR DENTAL IMPLANTS

  1. Smoking: Do not smoke. Patients who smoke will experience delayed healing and greater discomfort and are at higher risk for infection. In addition smoking will compromise your result.
  2. Medication:It is important to follow the instructions written on your prescription. If you experience any unfavourable reactions such as nausea, vomiting, diarrhea, rash, etc. call the doctor.
  3. Rest:Do not plan on any activities for the remainder of the day. Avoid any strenuous activity for 1 week following surgery.
  4. Pain:Some discomfort is expected once the anesthetic wears off. If you were prescribed post-operative pain medication, begin taking it before the anesthetic wears off to minimize discomfort. Ibuprofen is an effective pain medication and also reduces swelling. It can be taken for the first 3-4 days on a continuous basis (4 times per day) with a maximum dose of 3 grams per day. You may take Ibuprofen in addition to and at the same time as a prescribed narcotic such as Tylenol #2 or #3.
  5. Swelling: Some swelling may occur the day after surgery and will generally persist for 24-36 hours, then diminish.Swelling can be minimized by placing an ice pack on the outside of the face over the surgical site alternating on and off in 10 minute intervals. You should do this forthe 24 hours following your surgery.
  6. Bleeding:There should be no outright bleeding after surgery, though a slight pinkish colour to your saliva is common. If bleeding occurs, place a moistened non herbal tea bag over the area and apply gentle pressure. Continue this for 20 minutes. If bleeding persists call the doctor.
  7. Rinsing:Following your surgery you should rinse with warm salt water for the next 24 hours. Do not brush or floss or water pik in the area involved in the surgery. If you have been prescribed mouthwash use it twice daily until the stiches are removed. Make sure there is no toothpaste in your mouth when rinsing.
  8. Diet:It is important to maintain a normal healthy diet. Do not drink any hot drinks for the first 24 hours. The 4 days following surgery eat soft foods (oatmeal, cottage cheese, eggs, avocado, fruit and vegetable juices) Try to do your chewing on the opposite site of your mouth from where the surgery took place. Avoid any coarse foods such as seeds, nuts, chips, popcorn etc. . . . It may be necessary to maintain a liquid diet for a few days. Increase your fluid intake during this time. Avoid using a straw for 4 days.

Dr. Brian Kumer

(416) 605-0008

Pre Sedation Instructions

PRESEDATION INSTRUCTIONS

This type of sedation will produce a dream like state. Most people will become indifferent to the dental procedure after the sedation takes effect. The sedation is given Intravenously Please follow the instructions below

1) Do not eat or anything 8 hours prior to your appointment or drink anything other than water, clear apple juice, ginger ale, clear tea or black coffee (NO MILK or CREAM) for 3 hours prior to appointment. Take the medication prescribed by your M.D; as long as its 3hrs prior to your appointment.

2) Do not wear contact lenses to the appointment.

3) No alcohol for 12 hrs. before your appointment.

4) Please wear a short sleeved shirt. No nail polish, including clear.

5) You must have a responsible person with you to escort you home and be given post sedation and surgical instructions. You may not take public transit or a taxi home unescorted!

6) Do not drink grapefruit juice 24hrs prior to surgery.

7) Please advise our office of any medications that you are taking whether prescribed or over the counter.

8) Contact us prior to your appointment if there has been a change to your general health.

IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL

Dr. Brian Kumer

416 605-0008

Post Sedation Instructions

POST SEDATION INSTRUCTIONS

1) Do not drive or operate hazardous equipment for 24hrs after sedation.

2) A responsible person should remain with the patient until they are fully recovered from the effects of sedation.

3) Patients must not go up or down stairs unescorted for 24hrs.

4) No unattended bath or shower for 24 hrs.

5) Diet is restricted by surgical procedure not the sedation.

6) Drink plenty of fluids, 1.5-2 litres per day in the first three to four days.

7) Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner.

8) Don’t use any pillows for the first night.

9) No alcohol for 24hrs

10) Do not sign any important or legal documents for 24hrs.

11) Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately.

Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killers are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist.

DR BRIAN KUMER

(416) 605-0008

IVCS consent form

Dr. Brian Kumer DDS

Consent for I.V. Conscious Sedation

This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation.

The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year.

I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent.

I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother.

Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation.

I have been advised of and completely understand the risks, benefits, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer.

I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees.

I certify that I fully understand the terms within the above consent.

I can read and write English ____ Yes____ No

Print Patient’s Name: _________________________________________________________________

Print Parent/Guardian’s Name (if applicable): ______________________________________________

Signature: _____________________________________________Date: _________________________

Qualification Declaration

APPENDIX TO DENTAL IMPLANT INFORMED CONSENT


I understand that Dr. Brian Kumer is NOT AN ORAL SURGEON but a general dentist who has several years experience in the placement of dental implants and always uses his best efforts to provide the appropriate treatment for patients.

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