Implant And Bone Graft Consent Form Page 2
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2o Graft material will be placed in the areas of bone loss around the teeth/implant various types of graft
materials may be used. These materials may include my own bone, synthetic bone substitutes, or bone
obtained from tissue bank (allografts). Membranes may be used with or without graft materials-
depending the type of bone defect present. I understand that some patients don’t respond successfully to
bone regenerative procedures. The procedure may not be successful in preserving function or
appearance. Because each patient’ conditions is unique, long term success may not occur. In rare cases
the involved implant/bone graft may ultimately be lost.
Initials_______
o I certify I have read and understand the above. I accept the risk of substantial and serious harm, if any,
in hope of obtaining the desire beneficial result of the treatment or procedures. I acknowledge Dr.
Khansari has explained all of the above to me in a thorough and comprehensive manner, and all
questions about my treatment and its risks have been answered to my satisfaction. I give my consent for
the proposed treatment as described above.
Initials_______
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_______________________________
______________________________
Date
Print name of patient parents or legal guardian
Signature of patient, parents, or legal guardian
_________________
__________________________________________ _____________________________________
Date
Print name of Witness
Signature of witness
_________________
________________________
Date
Signature of Periodontist
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