Dental Implant And Patient Information And Consent Form printable pdf download

Robert H. Bridgeman, D.D.S., P.A.

(828) 264-7272

2348 Hwy 105, Suite 1, Boone, NC 28607

Dental Implant and Patient Information and Consent Form

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

procedure. I understand what is necessary to accomplish the placement of the implant

under the gum and the bone.

2. My doctor has carefully examined my mouth. Alternatives to this treatment, including

no treatment, have been explained. I have tried or considered these methods, but I

desire an implant to help secure the missing teeth.

3. I have further been informed of the possible risks and complications involved with

surgery, drugs, and anesthesia. Such complications include pain, swelling, infection

and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The

exact duration may not be determinable and may be irreversible. Also possible are

inflammation of a vein, injury to other teeth, bone fractures, sinus penetration, delayed

healing, allergic reactions to drugs or medications, etc.

4. I understand that if nothing is done, any of the following could occur: bone disease, loss

of bone, gum tissue inflammation, infection, sensitivity, looseness, or drifting of teeth,

followed by necessity of extraction. Also possible are temporomandibular (jaw) joint

problems, headaches, referred pains to the back of the neck and facial muscles, and

tired muscles when chewing.

5. My doctor has explained that there is no method to accurately predict the gum and the

bone healing capabilities in each patient following implant placement.

6. It has been explained 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 assurance as to the outcome of results of treatment or surgery can be

made. I understand that if my implants fail prior to the final restoration by my doctor

within 6 months of placement, my doctor will remove and replace the implant at no

charge to me, or if I elect to have the implant removed permanently, then I will be

refunded half the cost of the implant placement (excluding materials).

7. I understand that excessive smoking, alcohol, or sugar may affect gum healing and may

limit the success of the implant. I agree to follow my doctor’s home care instructions. I

agree to report to my doctor for regular examinations as recommended.

8. I agree to the type of anesthesia, depending on the choice of the doctor. If I have taken

a sedative prescribed by my doctor prior to this appointment, I agree not to operate a

motor vehicle or hazardous device for at least 24 hours or more until fully recovered

from the effects of the sedative or drugs given for my care.

Dental Implant And Patient Information And Consent Form