I hereby consent to the surgical placement of dental implants as well as the prosthetic
portion of the implant which will be inserted once healing is fully successful.
I understand that the purpose of the dental implant is to provide support for dental prosthetic
reconstruction in the form of a single tooth, bridge, or denture, or to provide orthodontic
anchorage. Dental implants are metal anchors put inside the jawbone underneath the gum line.
Small posts are attached to the implants, and artificial teeth or dentures are fastened to the posts.
Most patients need two surgical procedures to install the implants.
The first procedure involves drilling small holes into the jawbone and placing the
anchors. You will be given anesthetic to numb the pain. You will also be put on antibiotics and
be given pain medication. A temporary denture or flipper may be worn for a few months while
the anchors bond with the jawbone and the gums and bone heal. The second procedure which
usually will occur 3-6 months after implant placement, will uncover the implants to allow for
attachment of the posts. After the posts are in place, the replacement teeth, in the form of fixed
or removable bridgework or a denture, are fastened to the posts. Depending on the condition of
the mouth, bone grafting or guided tissue regeneration also may be necessary to install the
anchors and posts.
At present, At present, we cannot predict the length of time dental implants will provide service in
the oral cavity. I know that smoking lowers the chances of implant success in direct proportion
to the amount smoked. 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 understand the alternative conventional dental treatment options and I am
aware of the consequences of receiving no treatment.
The potential benefits
of this procedure include the replacement of missing natural teeth
or supporting dentures. I have chosen to undergo this procedure after considering the alternative
forms of treatment for my condition, which include no treatment at all, complete or partial
dentures, or fixed or removable bridges. Each of these alternative forms of treatment has its own
potential benefits, risks and complications.
I consent to the administration
of anesthesia or other medications before, during or after
the procedure by qualified personnel. I understand that all anesthetics or sedation medications
involve the very rare potential of risks or complications such as damage to vital organs
including the brain, heart, lungs, liver and kidneys; paralysis; cardiac arrest; and/or death from
both known and unknown causes.
I understand that
the implant surgery and prosthetics will be done in the established way
and that the risks in the front of the mouth consist of the usual ones associated with simple gum
surgery including, but not limited to pain, swelling, bruising, infection and bleeding. Additional
complications have been reported for implant surgery in the back of the mouth; they consist of
loss of sensation to the tongue, cheeks or lip on the treated side in the lower jaw, and the
creation of a communication between the sinus and the mouth on the treated side in the upper
jaw . Other complications may include trauma to the nerve tissue or blood vessels that
may lead to loss of sensation of lip tongue check or other tissues in the mouth or altered
sensation or pain . These complications would require further surgery for correction.
I agree to make every
effort to return for follow-up visits for hygiene and exams three
months, six months, one year, eighteen months and two years after the surgery and to have the
needed x-rays taken as well as any cleaning and adjustment procedures needed to keep my
mouth healthy at the usual and customary fees, but I am aware that this is entirely voluntary on
my part. 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.
Photographs and clinical data might be used in scientific papers and presentations and the
confidentiality of the patient will be respected.
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
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.