The Loving Dentist - After Hours Care

Dental Implant Consent

I, hereby give permission to the above named office to surgically place DENTAL IMPLANT(S) and such additional procedures as are considered necessary on the basis of findings during the course of said treatment.

I have been informed of alternative treatment options, benefits and possible risks and after the dentist’s explanation, I have chosen said treatment. I understand there are various inherent or potential risks that can occur as a result of said procedure despite all efforts to the contrary which include but are not limited to:

1. Pain, swelling, bleeding, and/or bruising which may require further treatment

2. Changes in occlusion (biting) and/or damage to existing restoration which may require replacement

3. Stiffness of the nearby muscles or cramps in the jaw muscles

4. It might be hard to open my mouth for several days. This might be from swelling and muscle soreness, or from stress on the jaw joints (TMJ)

5. Damage to nearby teeth during said procedure that may require additional treatment or even result in tooth loss

6. An infection after said procedure which may require additional treatment or cause loss of the implant

7. Stretching of the corners of the mouth that might cause cracking and bruising and might heal slowly

8. Drug reactions and side effects to any medications or materials used in said procedure

9. During the surgery, pieces of bone, synthetic bone or synthetic membranes may be placed which may become infected or devitalized and require antibiotics or additional surgery

10. Post-operative bleeding or infection that may require treatment

11. Involvement of the nerve within the lower jaw resulting in temporary (but possible permanent) loss of taste, tingling and/or numbness in the lip, chin, tongue, gums, cheeks,
and teeth

12. The jaw may break and require additional surgical treatment for repair

13. The use of other materials such as synthetic membranes that might require removal at a later date

14. Bone loss around implants and/or adjacent teeth

15. Fracture of the implant or restorative parts

16. Loss of an implant or implants

17. Aspiration and/or swallowing of foreign objects

18. Involvement of the sinus of the upper jaw requiring possible surgery for repair at a future date

I understand that my gum tissue will be opened to expose the bone, and one or more implants will be threaded into holes made in the bone. The implants will be the support for one or more missing tooth replacements to hold a crown, bridge, partial denture or complete denture. The doctor has explained the procedure to me.

Sometimes dental implants remain covered by the gum tissue during the initial healing period. If the implant is covered by gum tissue, it will have to be surgically uncovered before it can be restored by the dentist. Sometimes dental implants are left exposed through the gum tissue when placed. Gum tissue grafting or trimming may be necessary before or after restoration by the dentist.

No one has promised how long the implants will last. I have been told that once the implant is placed, I need to follow through with the entire treatment plan and finish it within the time period that is set by my doctors. If this is not done, the implants may fail. If my doctor finds a different condition than expected and feels that a different surgery or more surgery needs to be done, I agree to have it done. I am aware the practice of dentistry is not an exact science and acknowledge that no promises or guarantees of results have been made nor are expected. I have read and understand the above and give my consent to surgery. I have given a complete and truthful medical history, including all
medicines drug use, pregnancy, etc. All of my questions have been answered before signing this form.

Signed on

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Signed by The Loving Dentist After Hours Care
Signed On: April 4, 2018

The Loving Dentist - After Hours Care
Signature Certificate
Document name: Dental Implant Consent
Unique Document ID: cb99296228313e4b3f2fe3c87ac48f7d8640ab6c
Timestamp Audit
April 4, 2018 12:42 pm EDTDental Implant Consent Uploaded by The Loving Walk-In Dental Clinic of Orlando - IP