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.
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.