Consent Form Dental Implant(S) (Page 2 of 4) in pdf

request that the doctor and his associates or assistants under his direction perform such procedure as found

necessary and administer such drugs and treatments as required in their professional judgment.

6. I have had the opportunity to discuss with the doctor the planned surgical procedure, implant

placement, and my postoperative responsibilities. I understand that following the procedure during the healing

process I should not smoke, drink heavily, use any drugs not prescribed by my doctor, should not blow my nose

for at least 2 weeks and thereafter not heavily blow my nose for an additional 2 weeks. I should take any

antibiotics prescribed and use pain medication as needed. If I experience an unusual amount of pain, I should

contact the doctor or his associates immediately, because it may signify a problem.

7. I understand that anesthesia given during surgery and certain prescription medications used after

surgery cause drowsiness and impaired physical performance, and that such effect is increased by the use of

alcohol, and that I must not operate a motor vehicle or any other hazardous equipment while taking these drugs.

I also agree not to operate a motor vehicle or any other hazardous equipment for at least 48 hours after my

release from surgery.

8. I understand no guarantee has been given to me that the proposed treatment will be curative and/or

successful to my complete satisfaction. I also understand that due to individual patient differences and the

imperfections of the art and science of surgery, there is a risk of failure or necessity of additional treatment

despite appropriate care. I have been advised that the placement of root form implants has shown long-term

success rates. However, I understand that such disclosure is not to imply that I personally can expect such a

favorable long-term result and that there will be no refund of fees from the surgeon or restorative dentist in the

event of complications requiring additional surgery to salvage the implant or failure requiring removal of part or

all of the implant. I further understand that should removal be required, the doctor will remove the implant at no

additional cost. However, if I elect to have another doctor remove the implant, I am solely responsible for all

costs and fees incurred in doing so and hereby release the doctor from any such costs and fees imposed by the

other doctor.

Alternatives

My physician has explained the following medically acceptable alternatives: A bridge, a partial denture, full

denture, or other options.

Also, I can seek specialized care somewhere else, or I can have nothing done.

Consequences of not Having Procedure Performed

If I don't have the procedure, my condition may stay the same or even improve. However, it is the doctor's

opinion that the proposed procedure is a better option for me. If I don't have the procedure, the following may

also happen: Further loss of supporting tissues or bone; a gap in the teeth.

Other Procedures

During the course of the procedure, the doctor may discover other conditions that require an extension of the

planned procedure, or a different procedure altogether. I authorize the doctor to perform the procedures at this

sitting rather than later on.

Risks

The doctor will give his or her best professional care toward accomplishment of the desired results. The

substantial and frequent risks and hazards of the proposed procedure are restricted mouth opening, gum

shrinkage, clicking or pain of the temporomandibular joints (jaw joints), tooth sensitivity to hot or cold for days

up to months, loose teeth, food lodging between the teeth requiring flossing for removal, and unaesthetic

exposure of crown margins of teeth in the surgery area. These are usually temporary. Uncommonly, these

effects may persist. Uncommon risks also include interference with speech sounds and permanent nerve injury,

which could require nerve graft surgery.

There will be no refund of fees from the surgeon or restorative dentist in the event of complications requiring

additional surgery to salvage the implant or failure requiring removal of part or all of the implant. If removal is

Consent Form Dental Implant(S) Page 2

Related Articles

Related forms

Related Categories