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.
Fixed- Similar to natural teeth in color and size.
Fixed- Longer and/or larger than natural teeth, and of similar color.
Fixed- Longer and/or larger than teeth, with tooth color and pink to replace missing gum.
Removable- Supported by implants.
Removable- Supported by implants and gums.
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.
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 implant. 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 no 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, xrays,
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
I consent to photography, filming, recording, x-rays, and additional professional staff observing
the procedure to be performed for the advancement of implant dentistry, provided my identity is
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.
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and 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.