Implant And Bone Graft Consent Form
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2IMPLANT AND BONE GRAFT CONSENT FORM
Please take a moment and read this consent form carefully and ask your questions.
o I have been informed and I understand the purpose and the nature of the implant surgery procedure. I
understand what is necessary to accomplish the placement of the implant under the gum or in the bone.
Initials_______
o My doctor has carefully examined my mouth. Alternatives to this treatment have been explained, I have
tried or considered these methods, but I desire an implant to help secure the replaced missing teeth.
Initials_______
o I have further been informed of the possible risks and complication involved with surgery, drugs, and
anesthesia. Such complications include but not limited to 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 teeth present,
bone fractures, sinus penetration delayed healing, allergic reactions to drugs or medications used. Etc.
Initials_______
o Dr. Khansari has explained that there is no method to accurately predict the gum and the bone healing
capabilities in each patient following the placement of the implant.
Initials_______
o It has been explained that in some instances implants, bone grafts 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 can be made.
Initials_______
o I understand that smoking, alcohol or sugar may effect gum healing and may limit the success of the
implant. I agree to follow y doctor’s home care instructions. I agree to report to my doctor for regular
examinations as instructed.
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o I agree to the type of anesthesia, depending on the choice of the doctor. I agree not to operate a motor
vehicle or hazardous device far at least 24 hours or more until fully recovered from the effects of the
anesthesia or drugs give for my care.
Initials_______
o To my knowledge I have given an accurate report of my physical and mental health history. I have also
reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust,
blood or body disease, gum or skin reactions, abnormal bleeding or any other condition related to my
health
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o I consent to photography, filming, recording, and xrays of the procedure to be performed for the
advancement of implant dentistry, provided my identity is not revealed.
Initials_______
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