Forms

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.

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 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

I authorize Dr. Stephen Ing and associates/assistants of his choice to perform intravenous sedation/anesthesia, as a part of my dental procedure. Additionally, I authorize the performance of any other procedure that in the judgment of Dr. Ing may be necessary for my well-being, including such interventions that are considered medically advisable to remedy conditions encountered during the proposed procedure.

I am satisfied with my understanding of the nature of the anesthesia plan of care and the more common drawbacks and complications associated with it. These may include, but are not limited to: swelling, bleeding or discomfort at the site of intravenous insertion; allergic reactions to the anesthetic agents used; nausea and/or vomiting; prolonged recovery from anesthesia; post-operative disorientation/delirium (temporary); aspiration of stomach contents (rare); sore throat; fractured teeth; sore/bleeding nose. There is also a very rare potential for serious harm, including respiratory and cardiac arrest which can result in brain damage or death. I understand the risks, complications, and potential benefits of anesthesia. I have been given ample opportunity to discuss alternative methods of treatment, if any, along with their risks and benefits. No warranty or guarantee has been made as to the outcome of the anesthesia plan of care.

I understand that in some instances where a general anesthetic (ie, completely asleep/unconscious) has been specifically requested, Dr. Ing may use a breathing tube to ensure that the patient's airway remains unobstructed during the procedure. In these instances, there is an increased chance of a temporary sore throat or in much rarer circumstances, physical trauma to the airway.

I understand that anesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Ing of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation/anesthetic. For similar reasons, I understand that I must inform Dr. Ing if I am a nursing mother.

I understand and agree to the following post-anesthetic instructions:

1. I will not drive a car or operate machinery for at least 24 hours, longer if drowsiness or dizziness persists.
2. I will not drink alcoholic beverages for a minimum of 24 hours after the procedure.
3. I will be in the care of a responsible adult until I am fully alert.

PRE-OPERATIVE INSTRUCTIONS FOR PATIENTS WHO WILL BE RECEIVING SEDATION OR ANESTHESIA

1. Nothing to eat or drink (including water) for 8 hours before the procedure.
2. The only exception to the above instruction applies if you take medications on a regular basis. Take your usual medications at (approximately) the regularly scheduled times at least two hours before the appointment, with a few sips of water (and water only).
3. Arrangements must be made to have a responsible adult take you home, by car or taxi (a taxi driver alone is not allowed to take you home). You may NOT go home by public transit.
4. Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish.
5. Contact us prior to the appointment if has there been a change in your general health (egs, severe cold, fever, etc.)

INSTRUCTIONS FOLLOWING YOUR SEDATION/ANESTHESIA APPOINTMENT

1. You may be drowsy for the remainder of the day and should be relaxing at home in the care of a responsible adult until you are fully alert.
2. You must not drive a car or operate machinery for at least 18 hours, longer if drowsiness or dizziness persists.
3. Replenish your energy by having something to eat or drink as soon as possible.
4. Do not drink alcoholic beverages for a minimum of 18 hours after the procedure.
5. Do not sign any important or legal documents for 24 hours.
6. If there are any questions or concerns, contact the dental office. In case of an emergency, you should go to the nearest emergency room.

APPENDIX TO SURGICAL INFORMED CONSENT

Patients Name: _________________

I understand that Dr. Brian Kumer is not an oral surgeon. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery.

______________________________

Date

______________________________

Patient’s Signature

_____________________________________

Parent’s Signature

___________________________________________________________________

If you take Blood thinners including ASA

DO NOT STOP taking them prior to your dental procedure.Please check with Dr. Kumer first.

If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please emaildrkumerquestions@gmail.com