The removal of an implant is a surgical procedure. As with any surgical procedure there are some
risks. These risks include, but are not limited to the following:
1. Swelling and/or bruising and discomfort in the surgical area.
2. Stretching of the corners of the mouth resulting in cracking or bruising.
3. Possible infection requiring additional treatment.
4. Trismus, or limited jaw opening due to inflammation or swelling, most common after wisdom tooth
extraction. Sometimes this is a result of jaw joint discomfort (TMJ), especially when a TMJ disorder
5. Bleeding - significant bleeding is not common, but persistent oozing can be expected for several
hours. Serious complications are not expected. Those which do occur are most often minor and can
6. 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.
I give my full permission for Dr. _________________ (please write the name of the doctor below) to remove my implant(s). I understand the risk
and benefits of this procedure and have been given the ability to ask questions to the clinician. I also
give my permission to receive supplemental membranes, bone grafts, or other types of grafts to build
up the ridge of my jaw thereby assisting in placement, closure, and security of future placement of an
implant, which may require additional charges.
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.