Informed Consent For Implant Placement printable pdf download

M E N L O PA R K D E N TA L E X C E L L E N C E

ChauLong Nguyen, D.D.S., M.A.G.D.

724 Oak Grove Avenue, Suite 120

Menlo Park, CA 94025

(650) 838-0260

INFORMED CONSENT FOR IMPLANT PLACEMENT

The doctor has explained the beneﬁts and risks of dental implants to me. I understand

that implants involve the placement of a titanium root form structure into the bone. I

further understand that implant treatment is complex and includes the need for proper

prosthetic restoration. I also understand that the placement of the implant device and

associated risks are separate from the restoration of the implant and associated risks.

I understand that the implant ﬁxture may require a second surgery, usually four to nine

months later to uncover the implant device. At the time of this second surgery it is

occasionally necessary to add more gum or bone in the area. If this is the case there will

be additional fees for these services.

I understand the number and location of implant devices will depend on the availability of

adequate bone to support the implant and the number of teeth that need to be replaced.

There may be involvement of the sinus cavities when the implants are placed in the upper

jaw. Surgery in the upper back areas of the mouth runs the risks of sinus perforations.

Alternate treatments have been explained to me. It has been explained to me that one

option is to do nothing. I understand the risks of no treatment may include, but are not

limited to: loss of bone and gum tissue; jaw joint problems, headaches, and referred pain;

sensitivity, inﬂammation, infection, and migration of teeth.

I understand and accept the treatment recommended for me by the doctor. I further

understand that there may be some unwanted complications, some of which are listed

below. No guarantees have been made or implied. I also understand that implant

supported prosthesis requires continuing professional monitoring, may require additional

treatment in the future, and success is dependent upon home care. I realize implants may

become loose and need to be removed or replaced at additional costs. All of my

questions have been addressed.

Treatment risks/unwanted consequences may be (but are not limited to):

•

Reaction to medications/anaesthetic

Informed Consent For Implant Placement