Dental Implant Surgical Consent Form printable pdf download

DENTAL IMPLANT SURGICAL CONSENT FORM

I___________________________, have been informed and understand that

transitional or “mini implants” are available to certain dental patients. These mini

implants are small diameter (1.8mm) titanium alloy dental implant screws that are

placed in a patients jaw to provide immediate and on going stabilization of teeth. I

am aware that these implants are being placed for the immediate and on- going

stabilization of my dental prosthesis and the long term function cannot be predicted.

I wish to undergo this procedure as a patient of Dr. M. Thomas Edwards, Jr. I have

requested Dr Edwards to place one or more mini dental implants into my jaw.

I have also been fully informed by Dr Edwards that the purpose of this dental

implant procedure is to provide support for my lower jaw and to enhance the

function, and I hereby consent to the surgical insertion of mini dental implants in

my jaw by Dr. Edwards. I understand that in the event in the event that the mini

dental implants implanted by Dr. Edwards fail they will be removed through a

subsequent surgical procedure. I further understand that it is possible that one or

more of the implants may fracture during insertion, or during the implant’s life

cycle, and in event that such a fracture occurs, I give Dr. Edwards permission to

leave the fracture in my jaw or to remove it under professional conditions and using

professional judgment. It has also been explained tome that once the mini implants

are inserted or implanted, a recommended dental treatment plan, including a

program of personal oral hygiene must be strictly followed by me and completed on

schedule. I have been informed that if this schedule and plan are not carried out, the

implants may fail.

I am further aware that the surgical procedure includes the insertion of the mini

dental implants into the jaw, and possibly the construction of a prosthetic device. I

am aware that I must return for appropriate post operative care and evaluation on

a timely basic which will include evaluation of oral hygiene and plaque removal.

I also understand that function and comfort will be primary goals of this dental

procedure but that success rates of each patient vary. With that in mind, no

guarantees of success have been given to me by Dr Edwards or any member of this

staff. He has also informed me that use of tobacco, including cigarette smoking, as

well as excessive alcohol consumption can cause failure of dental implants.

I have further been advised that swelling, infection, bleeding, and or pain may be

associated with any surgical procedure, including the one recommended to me by

Dr. Edwards, and said conditions may occur during the life of the implants. I have

also been advised that temporary or permanent numbness may occur in my tongue,

lips, chin, gum or jaw. Dr Edwards has discussed the possibility of alternative

procedures for my individual needs and has offered to answer any of my questions

concerning those procedures.

Dental Implant Surgical Consent Form