Patient Consent printable pdf download

Diagnosis. After careful oral examination, a review of radiographs and study of dental condition, my dentist

advised me that my missing tooth or teeth might be replaced with artificial teeth supported by an implant or

implants.

Recommended Treatment. I have been presented with the following options for treatment.

1. No treatment.

2. Limited use of a new partial denture for eating and public appearance.

3. Crown and bridge-work (if possible).

4. Placement of titanium implant fixtures into the existing bone of the jaw, which will be used to

support new restorations, fixed bridgework, or a removable denture.

I have selected the option of placement titanium fixtures into the existing bone of the jaw.

I am aware of the benefits and have been informed of the surgical and restorative procedures, and the risks

involved.

Surgical Phase of Procedure. I understand that sedation may be utilized and that a local anesthetic will be

administered to me as part of the treatment. My gum tissue will be opened to expose the bone. Implants will

be placed, by tapping or threading them, into the holes that have been drilled into my jawbone. The

implants will have a snugly fit and will be held tightly in place during the healing phase.

The gum and soft tissue will be stitched closed over or around the implants. A periodontal bandage or

dressing may be placed. Healing will be allowed to proceed for a period of three to nine months. I

understand that dentures usually cannot be worn during the first two weeks of the healing phase.

I further understand that if clinical conditions turn out to be unfavorable for the use of this implant system,

or prevent the placement of implants, my dentist will make a professional judgment of the management of

the situation. The procedures also may involve supplemental bone graft or other types of grafts to build up

the ridge of my jaw, and thereby to assist the placement, closure, and security of my implants. This may

also include the placement of bone grafts into the maxillary sinuses to increase the height and width of bone

for the appropriate insertion of implants for use as “back” teeth.

After the surgery, there may be temporary pain, swelling, discoloration of the skin, and numbness or altered

sensation. If sinus grafts are used, there may be nosebleeds.

Patient Consent