Informed Consent Form For Implant Surgery printable pdf download

Informed Consent Form For Implant Surgery

INFORMED CONSENT FORM FOR IMPLANT SURGERY

1. I, ________________________________, hereby authorize and request Dr.

____________ and his assistants to perform implant surgery upon me.

2. I have been informed and I understand the purpose and nature of the implant surgery.

__________ has explained to me that implant surgery is a surgical procedure whereby local

anesthesia is utilized to numb the area, an incision is made into the gums and the gums are

reflected back, a hole is then drilled into the bone, and an implant is then placed into that area.

The gums are then surgically closed, allowed to heal, and subsequent to that a restoration is

placed on top of the implant. In essence, an implant is an artificial tooth which is surgically

placed into the jaw bone.

3. I have been advised by

that there are no guarantees to the

successful placement of an implant or implants into my mouth. I understand and have been

advised that the possible risks and complications involved with implant surgery include adverse

reactions to anesthesia and/or drugs utilized resulting in numbness, infection, allergic reaction,

rash, discoloration, and even in some cases cardiac death. I understand that, with respect to

implant surgery, there are also material risks and complications including but not limited to pain,

swelling, infection, and discoloration. I also understand that, with respect to implant surgery,

there are risks including altered sensation, tingling, shooting pain, and numbness of the lip,

tongue, chin, cheek, bone, and teeth which may occur and that this numbness may be temporary

or permanent in nature. I also understand that the risks of implant surgery include damage or

inflammation to veins and/or arteries, injury to surrounding teeth, bone fractures, sinus

penetration, or perforation, sinus hole, delayed healing, abscesses, an infected socket, changes in

my bite, trismus which is a difficulty opening the jaw, tempormandibular joint injury and

Informed Consent Form For Implant Surgery