Dental implant consent form

Please read and sign this important form as confirmation that we have discussed the nature, purpose, cost and alternatives to dental implant treatment as well as the risks involved. It is alsoconfirmation that you feel the points below have been discussed in depth and you have beengiven opportunity to ask questions and they have been answered to your satisfaction.

Please read this form carefully and only sign it when you fully understand all of the points below.

1. I understand that dental implant treatment is one of a few options for dental treatment whichhave been explained to me. The other options may include accepting spaces, dentures orbridge work. I have chosen dental implants as my preferred choice to act as a support for anew crown/bridge/denture. Antibiotics and analgesics are commonly used as part of this treatment and I am not allergic to these drugs.

2. I understand that the procedure involves surgery and I can expect to feel some soreness,swelling and stitches are very likely to be needed. Bruising can also occur. With any surgery Iaccept there is an infection risk and I may need to take antibiotics. I accept there are very small risks to nerves, blood vessels and other teeth during implant surgery. The risks to nerves arehighest in the lower jaw and can affect sensation to the lip and tongue on one side.

3. Doctor has explained to me that every effort is made to help and optimize gum healingfollowing extraction and implant placement but this will largely be determined by my body'snatural responses. This can mean gum recession can occur and the end result can look like aslightly longer tooth. Healing period of 4 to 6 weeks post implant placement with success rate of 95%, yet some critical factors that can affect the success rate of the implant including: Diabetes, Smoking, general ill health (including conditions which affect bone turn over and/or the consumption of bisphosphonatesdrugs).

4. All treatment is guaranteed for 12 months following treatment completion. This guaranteeexcludes failure due to neglect, smoking and trauma.

5. The restoration on the implant will require maintenance in the same way other forms of dentistrydo. The maintenance needed may be due to: implant screw loosening, screw fracture, implant fracture, chipping of the restoration or cement failure. This list is not exhaustive!

6. I agree to follow the home care instructions given to me (included in this pack).

7. I understand that x-rays and scans may be needed before, during and after treatment.Complex cases are more likely to require a CBCT scan.

8. In addition, if there is inadequate bone this may need to be built up by a bone substitute. Thepreferred substitute is a safe material combining synthetic, cow bone and pig collagen. I am aware thatthis may add an additional fee of minimumDHS 2500and the animal derived sources of these materials is clearto me and to be used during my surgery.

9. I have reported any previous incidences of allergic or unusual reactions to drugs, latex and anyserious illnesses or medications which I take. I have informed Dr. Yasser about any episodes ofprolonged or abnormal bleeding and to the best of my knowledge it is safe to carry out surgeryon me.

10. I am aware that meticulous oral hygiene is key to the long term success of my implant treatmentand I will do all I reasonably can to ensure the implants and their teeth are kept as clean as possible on a daily basis. If my implants fail in following years due to gum disease I accept theymay need surgical removal which will incur additional time and costs.

• I am fully informed of the nature of implant surgery.

• I am aware of the risks, complications and costs of implant surgery.

• I am aware of the alternatives to implant treatment.

• I have read this form and understand it fully, I therefore consent and request treatment.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature