Consent Form Dental Implant(S) (Page 3 of 4) in pdf

required, the doctor will remove the implant at no additional cost. If I have someone else remove the implant, I

am responsible for all costs and fees and will not ask the doctor to pay for it.

Drugs, Medications, and Anesthesia

Antibiotics, pain medication, and other medications may cause adverse reactions such as redness and swelling

of tissues, pain; itching; drowsiness; nausea; vomiting; dizziness; lack of coordination; miscarriage; cardiac

arrest (which can be increased by the effect of alcohol or other drugs); blood clots in the legs, heart, lungs, or

brain; low blood pressure; heart attack; stroke; paralysis; or brain damage. After injection of a local anesthetic, I

may sometimes have prolonged numbness and/or irritation in the area of injection. If I use nitrous oxide,

Atarax, chloral hydrate, Xanax, or other sedatives, possible risks include, but are not limited to, loss of

consciousness, severe shock, and stoppage of breathing or heartbeat. I will arrange for someone to drive me

home from the office after I have received sedation, and I will have someone watch me closely for 10 hours

after my dental appointment to observe for side effects such as difficulty breathing or loss of consciousness.

Implant Database

If a device is placed in my body, the doctor may give my name, dental information, social security number, and

other personal information to the device manufacturer for quality control purposes.

No guarantee

The practice of dentistry and surgery is not an exact science. Although good results are expected, the doctor has

not given me any guarantee that the proposed treatment will be successful, will be to my complete satisfaction,

or that it will last for any specific length of time. Due to individual patient differences, there is always a risk of

failure, relapse, need for more treatment, or worsening of my present condition despite careful treatment.

Occasionally, treated teeth may require extraction.

Part 3—My Responsibility

I agree to cooperate completely with the doctor's recommendations while under his or her care. If I don't fulfill

my responsibility, my results could be affected.

Success requires my long-term personal oral hygiene, mechanical plaque removal (daily brushing and flossing),

completion of recommended dental therapy, periodic periodontal visits (dental clinic care), regular follow-up

appointments, and overall general health.

There may be several follow-up clinical visits for the first year following surgery. It is my responsibility to see

the doctor at least once a year for evaluation of implant performance and oral hygiene maintenance.

I have provided an accurate and complete medical and personal history to the best of my ability, including those

antibiotics, drugs, medications, and foods to which I am allergic. I will follow all instructions as explained and

directed to me and will permit all required diagnostic procedures. I have had an opportunity to discuss my past

medical and health history, including any serious problems and/or injuries, with the doctor. .

Necessary Follow-up Care and Self-Care. Natural teeth and appliances should be maintained daily in a clean,

hygienic manner. I should follow postoperative instructions given after surgery to ensure proper healing. I will

need to come for appointments following the procedure so that my healing may he monitored and so that my

doctor can evaluate and report on the outcome of the surgery upon completion of healing.

I will not drink alcohol or take non-prescribed drugs during the treatment period. If sedation or general

anesthesia is used, I will not operate a motor vehicle or hazardous device for at least 24 hours or more until I

have fully recovered from the effects of the anesthesia or drugs.

I will let the doctor's office know if I change my contact information so I can be contacted for any recalls.

Part 4—Miscellaneous Photography

Consent Form Dental Implant(S) Page 3