Dental Implant Consent Form.60495e94b7423

Dental Implant Placement Consent Form
Patient name: _____________________________________
My doctor has explained the nature of my condition to me: Missing tooth or teeth.
My physician has proposed the following procedure to treat or diagnose my condition: Dental
implant
This means: Surgically place an implant into the supporting jawbone.
• Alternatives to this treatment have been explained.

• I further understand that no guarantees have been given by the doctor and/or
manufacturers of such dental implants and that cosmetic results achieved cannot be
guaranteed since it is a function of the circumstances in each case. Should an implant
fail, any additional fees are at the discretion of the doctor. I understand that the fee I
am to be charged has been disclosed to me and is satisfactory to me. I understand that I
am responsible, with or without the aid of my dental insurance, for all payment for any
procedures completed today.
• I have been informed that the purpose of this dental implant is to provide support for a
crown, bridge, or denture.
• I understand that the surgical procedure is for the actual placement of the implant(s),
and a second procedure is sometimes required for the exposure of the implant(s) and
attachment of the abutment for the crown, bridge, or denture to attach to.
• 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 extractions. Also possible are TMJ (jaw joint problems), headaches, referred
pain to the back of the neck and facial muscles, as well as sore muscles when chewing.
• The doctor will give his best professional care toward accomplishment of the desired
results.
While we believe that patients have a right to be informed about any treatment, the law
requires extensive disclosure of the risks of surgery and anesthesia, many of which are
extremely unlikely to occur, but can be alarming for the patient.
Please feel free to ask the doctor about the frequency of any risks or complications
disclosed herein that might apply to you based on our clinical experience and that of other
oral surgeons and implantologists.
• The substantial and frequent risks and hazards of the proposed procedure are:
Restricted mouth opening; gum shrinkage; clicking or pain of the temporomandibular
joints (jaw joints); tooth sensitivity to hot or cold for days or months; loose teeth; food
lodging between the teeth requiring flossing for removal; and unaesthetic exposure of
crown margins of teeth in the surgery area. These are usually temporary. Uncommonly,
these effects may persist.
• Uncommon risks also include: Interference with speech sounds; permanent nerve injury
possibly requiring nerve graft surgery.
• There will be no refund of fees from the surgeon or restorative dentist in the event of
complications requiring additional surgery to salvage the implant or failure requiring
removal of part or all of the implant. Should removal be required, the doctor will
remove the implant at no additional cost. If I have someone else remove the implant, I
am responsible for all costs and fees and will not ask the doctor to pay for it.
• Drugs; medications; anesthesia; antibiotics; pain medication; and other medications
may cause adverse reactions such as redness and swelling of tissues; pain; itching;
drowsiness; nausea; vomiting; dizziness; lack of coordination; miscarriage; cardiac
arrest, which can be increased by the effect of alcohol or other drugs; blood clot in the
legs, heart, lungs or brain; low blood pressure; heart attack; stroke; paralysis; brain
damage. Sometimes after injection of a local anesthetic, patient may have prolonged
numbness and/or irritation in the area of injection. When using nitrous oxide, Atarax,
chloral hydrate, Xanax, or other sedative, possible risks include, but are not limited to,
passing out, severe shock, and stopped breathing or heartbeat. I will arrange for
someone to drive me home from the office after being sedated, and to have someone
watch me closely for 10 hours after the dental appointment to observe for side effects
such as difficulty breathing or passing out.
• During the course of the procedure, the doctor may discover other conditions that
require an extension of the planned procedure, or a different procedure altogether. I
request the doctor to do the procedures deemed better to do at this sitting rather than
later on.
• I understand that I must return for follow-up at least two times a year for evaluation of
oral hygiene, plaque removal and a recall maintenance prophylaxis. If I fail to follow up
with my periodontal maintenance visits, I understand that I accept full responsibility for
failure of my dental implant and will not hold the doctor liable.
• I understand that the fee I am to be charged has been disclosed to me and is satisfactory
to me. I understand that I am responsible, with or without the aid of my dental
insurance, for all payment for any procedures completed today.
• I understand that the prosthetic treatments will be completed by my restorative dentist
such as abutments, bridgework, crowns, and/or dentures over implants, etc. I further
understand the fee for the dental implant does not include the prosthetic fee.
I hereby authorize and direct the doctor and his authorized associates and assistants to treat
my condition.
I have read and understand this form.
I have been encouraged to ask questions, and am satisfied with the answers. I give my informed
consent for surgery and anesthesia.
Someone at the doctor’s office has explained this form, my condition, the procedure, how the
procedure could help me, things that can go wrong, and my other options, including not having
anything done. I want to have the procedure done.
I authorize Dr. ___________________________________ or his designee (referred to in the

rest of this form as the doctor) to perform the procedure listed in the title above.
_______________________________________ __________________
Patient or representative signature Date
If not the patient, what is your relationship to the patient?
_________________________________________
I have explained the condition, procedure, benefits, alternatives, and risks described on this
form to the patient or representative.
_______________________________________ __________________
Dentist signature Date

Dental Implant Consent Form.60495e94b7423

Uploaded by

Copyright:

Available Formats

Dental Implant Consent Form.60495e94b7423

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dental Implant Consent Form.60495e94b7423

Uploaded by

Copyright:

Available Formats

Dental Implant Placement Consent Form

Patient name: _____________________________________

This means: Surgically place an implant into the supporting jawbone.

• Alternatives to this treatment have been explained.

I have read and understand this form.

I authorize Dr. ___________________________________ or his designee (referred to in the

Patient or representative signature Date

If not the patient, what is your relationship to the patient?

Dentist signature Date

You might also like