Implant Patient Information And Consent Form 1 I Have

implant patient information and consent form 1. i have been informed and i understand the purpose and the nature of the impl

Implant Patient Information and Consent Form
1.
I have been informed and I understand the purpose and the nature
of the implant surgery procedure. I understand what is necessary
to accomplish the placement of the implant under the gum or in the
bone.
2.
My doctor has carefully examined my mouth. Alternatives to this
treatment have been explained. I have tried or considered these
methods, but I desire an implant to help secure the replaced
missing teeth.
3.
I have further been informed of the possible risks and
complications involved with surgery, drugs, and anesthesia. Such
complications include pain, swelling, infection, and
discoloration. Numbness of the lip, tongue, chin, cheek, or teeth
may occur. The exact duration may not be determinable and may be
irreversible. Also possible are inflammation of a vein, injury to
teeth present, bone fractures, sinus penetration, delayed healing,
allergic reactions to drugs or medications used, etc.
4.
I understand that if nothing is done, any of the following could
occur: bone disease, loss of bone, gum tissue inflammation,
infection, sensitivity, looseness of teeth, followed by necessity
of extraction. Also possible are temporomandibular joint (jaw)
problems, headaches, referred pains to the back of the neck and
facial muscles, and tired muscles when chewing.
5.
My doctor has explained that there is no method to accurately
predict the gum and bone healing capabilities in each patient
following the placement of the implant.
6.
It has been explained that in some instances implants fail and
must be removed. I have been informed and understand that the
practice of dentistry is not an exact science; no guarantees or
assurance as to the outcome of results of treatment or surgery can
be made.
7.
I understand that excessive smoking, alcohol, or sugar may affect
gum healing and may limit the success of the implant. I agree to
follow my doctor’s home care instructions. I agree to report to my
doctor for regular examinations as instructed.
8.
I agree to the type of anesthesia, depending on the choice of the
doctor. I agree not to operate a motor vehicle or hazardous device
for at least 24 hours or more until fully recovered from the
effects of the anesthesia or drugs given for my care.
9.
To my knowledge I have given an accurate report of my physical and
mental health history. I have also reported any prior allergic or
unusual reactions to food, insect bites, anesthetics, pollens,
dust, blood or body diseases, gum or skin reactions, abnormal
bleeding, or any other conditions related to my health.
10.
I consent to photography, filming, recording, and x-rays of the
procedure to be performed for the advancement of implant
dentistry, provided my identity is not revealed.
11.
I request and authorize medical/dental services for me, including
implants and other surgery. I fully understand that during and
following the contemplated procedure, surgery, or treatment,
conditions may become apparent which warrant, in the judgment of
the doctor, additional or alternative treatment pertinent to the
success of comprehensive treatment. I also approve any
modification in design, materials, or care, if it is felt this is
in my best interest.
_______________________________________
_______________________________________
Signature of Doctor Signature of Patient
If the patient is unable to sign or is a minor
(signature of parent or legal guardian)
_______________________________________
Witness
_______________________________________
_______________________________________
Date Relationship to Patient