Date: May 18, 2021
Dr. has carefully examined my mouth. Alternatives to implant therapy have been explained. I have considered these methods and I desire implant placement to replace my missing teeth #.
I have been informed about the implant surgery procedure. The technique to accomplish placement of implants under the gum and in the bone has been explained to me.
I have been informed of the possible risks and complications involved with implant surgery. I have been told that all of these complications occur very infrequently. Such potential complications include pain, swelling, infection and transient discoloration. Numbness of the lip, tongue, chin, cheek or teeth may occur in a few cases. The exact duration of numbness is not predictable and infrequently may be irreversible. Also possible are: injury to adjacent teeth, bone, fracture, delayed healing and allergic reactions to drugs or medications used.
My dentist has explained that there is no method to accurately predict the gum and the bone healing capabilities in each patient following the placement of implants and that about 95% of implants successfully integrate into the bone. It has been explained that in a few instances implants fail and must be removed. Guarantees or assurance to the outcome of results of treatment or surgery cannot be made.
I understand that smoking may affect healing and limit the success of implants. I agree to follow my doctor’s home care instructions.
To my knowledge, I have given an accurate report of my physical history, allergy or any other conditions related to my health.
I request and authorize 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 for my best interest.
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