Informed Consent Form For Implant Surgery (Page 2 of 3) in pdf

Informed Consent Form For Implant Surgery Page 2

difficulty, myofacial pain dysfunction, which is a pain condition involving the muscles of the

face, the breakage of the implant necessitating its removal and/or being buried in the jaw,

lacerations, scars, and damage to the tissue, and injury to teeth with fillings, crowns, and bridges.

4. My doctor has explained to me that there is no method to actively predict the gum and

bone healing capabilities in each patient following the placement of the implant.

5. It has been explained to me that in some instances implants fail and must be removed.

I have been informed and understand that the practice of dentistry is not an exact science; no

guarantees or assurances as to the outcome of results of treatment or surgery have been made to

me.

6. I understand that there are alternative treatments include doing nothing, having a

crown or bridgework set up, or dentures. Dr. ________has explained to me the risks involved

with each one of these alternative treatments and I specifically reject them.

7. I understand that excessive smoking, alcohol, or sugar may effect the healing of my

gums and may limit the success of the implant(s). I agree to follow my doctor's home care

instructions strictly and I agree to maintain regular oral hygiene including regularly brushing my

teeth, regularly using dental floss, and utilizing mouthwash. I also agree to follow up with my

dentist for regular dental examinations and cleanings.

8. To my knowledge, I have given my dentist an accurate report of my physical and

mental health history. I have also reported any prior allergic or unusual reactions to foods,

drugs, anesthetics, and other conditions pertaining to my health.

9. I consent to photography, filming, recording, and x-rays of the procedure and the work

performed regarding the implant surgery.

Informed Consent Form For Implant Surgery Page 2