Consent Form Dental Implant(S)

ADVERTISEMENT

Consent Form Dental Implant(s)
Part 1—Patient and Doctor Information
Patient Name
____________________________________
Doctor Name
____________________________________
In order for me to make an informed decision about undergoing a procedure, I should have certain information
about the proposed procedure, the associated risks, the alternatives, and the consequences of not having it. The
doctor has provided me with this information to my satisfaction. The following is a summary of this
information. This form is meant to provide me with the information I need to make a good decision; it is not
meant to alarm me.
Part 2—Details of Consent
Condition
My doctor has explained the nature of my condition to me: Missing tooth or teeth.
Procedure-Dental Implant
My physician has proposed the following procedure to treat or diagnose my condition: Dental implant this
means: Surgically place an implant into the supporting jawbone. We believe that patients have a right to be
informed about any treatment, but the law requires extensive disclosure of the risks of surgery and anesthesia,
many of which are extremely unlikely to occur. These can be alarming for the patient. Please feel free to ask the
doctor about the frequency of any risks or complications disclosed herein that might apply to you (based on our
clinical experience and that of other oral surgeons and implantologists).
1. After a careful oral examination and study of my dental condition, the doctor has advised me that my
missing tooth or teeth may be replaced with artificial teeth supported by an implant. I hereby authorize and
direct the doctor and his authorized associates and assistants to treat my condition.
2. The procedure I choose to treat this condition is understood by me to be the placement of root form
implant(s). Additional treatment procedures may include a bone graft including materials of human, animal, or
plant origin. I understand that the purpose of this procedure is to allow me to have more functional artificial
teeth by the implants providing support, anchorage, and retention for these teeth.
3. I understand that this is nonetheless an elective procedure, that such procedures are performed to
improve function, and that an alternative option, although less desirable, is to not undergo surgery and do
nothing. I have also been advised that other alternative treatments performed for patients in my condition
include, but are not limited to, a bridge, a partial denture, full denture, or other options. I understand and choose
to undergo the placement of root form implant(s).
4. I understand that my gum tissue will surgically be opened to expose the bone and that implants will be
placed immediately by tapping or threading them into holes that have been drilled into my jawbone. I
understand that the gum tissue will then be stitched closed over or around the implant to permit healing for a
period of 3 to 6 months. I understand that dentures usually cannot be worn during the first few weeks of the
healing phase. I understand that the implants placed will be integrated within 3 to 9 months, depending on my
personal healing ability.
5. I also understand that during the course of the procedure, unforeseen conditions may arise that
necessitates an extension or alteration of the planned procedure contained herein. I therefore authorize and

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 4