INFORMED CONSENT FOR IMPLANT

TOOTH NO:

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 and 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 bruising. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also, possible inflammation of a vein, injury to teeth present, bone fractures, sinus penetration, delayed healing, and allergic reactions to drugs or medications used may occur.

4. I understand that if nothing is done, any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, and 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 the bone healing capabilities in each patient following the placement of the implant. Average time for an implant to integrate into the bone is 4 months for the lower jaw and 6 months for the upper jaw.

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.

I understand that excessive smoking, alcohol, or sugar intake 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 used, per the choice of the doctor. If I am sedated, I agree not to operate a motor vehicle or a hazardous device for at least 24 hours or more until I have fully recovered from the effects of the anesthesia or drugs given for my care.

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 drugs, 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 without my further permission.

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 of any modification in design, materials, or care, if it is felt this is in my best interest.

12. I acknowledge that I am financially responsible for all treatment rendered, including any additional procedures that may be required. I understand that all charges are to be paid in full and that the dental clinic, its doctors, and employees shall not be held liable for any financial obligations, costs, or expenses incurred during or after the treatment. Furthermore, I understand that there is a no refund policy after the completion of the treatment.

I hereby acknowledge that I have read and fully understood the information provided in this consent form. I voluntarily consent to undergo the implant procedure, acknowledging the associated risks and potential complications. I accept full financial responsibility for the treatment and any additional procedures deemed necessary. I release the dental clinic, its doctors, and staff from any liability arising from the treatment and its outcomes.

Patient Name:

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Witness Name

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Doctor name :

Dr.

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