The purpose of dental implant(s) is to provide stability, support and/or retention for a crown, fixed
bridge, fixed denture or removable denture in the absence of natural teeth. Based upon thorough
examination and discussion, I request the fabrication of an implant prosthesis. I approve any
future modification in prosthetic design, materials or treatment if, in the doctor’s professional
judgment, he feels that it is in my best interest.
Alternatives to this treatment have been explained. I have tried or considered these methods, but
I desire an implant prosthesis to help secure the replacement of my missing teeth. The entire
procedure has been fully explained, including the benefits and possible risks. I have been given the
opportunity to ask questions regarding the procedure and they have been answered to my
satisfaction. I have not asked for, nor have I received from anyone, a guarantee of the outcome of
The possible risks and complications for fixed prostheses include: compromised appearance
and/or lack of support of the lip(s) and cheek(s) as a result of inadequate bone; air escaping
underneath the prosthesis while talking which may adversely affect speech and/or food
entrapment underneath the prosthesis since space is necessary for homecare of the implant(s).
The possible risks for removable prostheses include: sore gums, food entrapment, wearing of
attachments, replacement of attachment components, and initial problems with speech.
Excessive forces, as grinding or clenching my teeth, on the implant(s) may lead to loosening and/or
fracture of the retaining screws or cement; fracture of the porcelain, metal or acrylic on the
prosthesis; loosening and/or fracture of the implant(s); and/or loss of bone around the implant(s).
Any of these may cause loss of this implant(s). Additional treatment and associated costs will be
involved should this occur, including, but not limited to occlusal guards.
I understand that if nothing is done any of the following could occur: loss of bone, gum tissue
inflammation, infection, sensitivity, looseness of teeth followed by necessity of extraction. Also
possible are temporomandibular joint, jaw problems, headaches, referred pains to the back of the
neck and facial muscles and fatigued muscles when chewing. In addition, I am aware that if
nothing is done at the present time, future bone loss may cause the inability to place implant(s) at
a later date due to changes in oral or medical condition(s).
It has been explained that in some instances implant(s) fail and must be removed. I have been
informed and understand that the practice of dentistry is not an exact science; therefore, I
understand there are no guarantees or assurances as to the outcome of treatment results.
Follow-up care for the implants and prosthesis is extremely important to the success. It will be
necessary to return to the office at regular intervals for examination and service. It has been made
clear that failure on my part to keep my mouth, implant post(s) and prosthesis thoroughly clean
may jeopardize the success of my implant(s). I realize that unforeseen long term factors may
necessitate additional surgery, modification of the implant(s) or even surgical removal of the
implant(s). I also understand that I will be financially responsible for long term maintenance
and/or any modifications required, including but not limited to cleanings, attachment
replacements, x rays, and examinations.
I have been informed and afforded the time to fully understand the purpose and the nature of the
implant restorative procedure. I understand what is necessary to accomplish the restoration of the
implant previously inserted into or onto the bone and under the gum.
To my knowledge, I have given an accurate report of my physical and mental health history. I
understand that excessive smoking, alcohol, or blood sugar may affect gum healing and may limit
the success of the implant(s) and restoration.I will report any significant change in my health
should it occur. It has been explained that in some instances implant(s) fail and must be
removed.I understand that in the event the implant fails to integrate, it must be removed through a
second surgical procedure, and there can be no refund of all or part of the fee for the lost implant.
I have been informed and understand that the practice of dentistry is not an exact science;
therefore, I understand there are no guarantees or assurances as to the outcome of treatment
results. I acknowledge that there is a chance that the implant(s) placed can fail and I am taking a
risk by agreeing to this surgical procedure.
It has been explained to me that once implants are inserted or implanted, a recommended
program of personal oral hygiene must be strictly followed by me and completed on
schedule. I have been informed that if this schedule and plan are not carried out, the
implants may fail.
I agree to make every effort to
return for follow-up visits for hygiene and exams after the
surgery in order to have any necessary x-rays taken but I am aware that this is entirely voluntary
on my part. Follow-up care for the implants and prosthesis is extremely important to the success
of the implants or Bone graft. It will be necessary to return to the office at regular intervals for
examination and service. Keeping your gums and teeth healthy by coming for hygiene visits every
3-4 months is one of the best ways to take care of your implants. It has been made clear that
failure on my part to keep my mouth, implant(s) and prosthesis thoroughly clean may jeopardize
the success of my implant(s). I realize that unforeseen long term factors may necessitate
additional surgery, modification of the implant(s) or even surgical removal of the implant(s). I also
understand that I will be financially responsible for long term maintenance and/or any
modifications required, including but not limited to cleanings, attachment replacements, x rays,
- Photographs and clinical data might be used in scientific papers and presentations and the
confidentiality of the patient will be respected.
I consent to the administration of anesthesia or other medications before, during or after the
procedure by qualified personnel.
There is a chance that during the course of the treatment unforeseen conditions may be
revealed that may require changes in the procedure noted above. I authorize the Dentist to
use professional judgement to perform such additional procedures that are necessary and
desirable to complete my procedure. If an unforeseen condition arises in the course of
treatment which calls for the performance of procedures in addition to or different that
now contemplated. I further authorize and direct my doctor to do whatever they deem
necessary and advisable under the circumstances, including the decision not to proceed
with the implant restoration.
I certify that I have read or had read to me the contents of this form. I will follow any patient
instructions related to this procedure. I confirm that the proposed treatment and potential
risks and/or complications associated with the procedure have been explained to me. I
understand the potential risks, complications and side effects involved with any dental
treatment or procedure and have decided to proceed with this procedure after considering
the possibility of both known and unknown risks, complications, side effects and
alternatives to the procedure. I declare that I have had the opportunity to ask questions and
all of my questions have been answered to my satisfaction.
IF YOU HAVE ANY QUESTIONS OR CONCERNS,
PLEASE FEEL FREE TO CONTACT THE OFFICE AT 905 770 0099 OR 416 223 2453
Once fully read and reviewed, please make sure that the above document is filled out
appropriately. By submitting this document, we are assuming that it has been read in its
entirety. All patient signatures will be verified for authenticity in the office.