appendix B Consent Form: Dental Implant(s)
Part 1—Patient and Doctor Information
Patient Name: _____________________________________
Part 2—Details of Consent
Procedure—Dental Implant
1. After a careful oral examination and study of my dental condition, the doctor has advised me that my missing tooth or teeth may be replaced with artificial teeth supported by an implant. I hereby authorize and direct the doctor and his authorized associates and assistants to treat my condition.
2. The procedure I choose to treat this condition is understood by me to be the placement of root form implant(s). Additional treatment procedures may include a bone graft including materials of human, animal, or plant origin. I understand that the purpose of this procedure is to allow me to have more functional artificial teeth by the implants providing support, anchorage, and retention for these teeth.
3. I understand that this is nonetheless an elective procedure, that such procedures are performed to improve function, and that an alternative option, although less desirable, is to not undergo surgery and do nothing. I have also been advised that other alternative treatments performed for patients in my condition include, but are not limited to, a bridge, a partial denture, full denture, or other options. I understand and choose to undergo the placement of root form implant(s).
4. I understand that my gum tissue will surgically be opened to expose the bone and that implants will be placed immediately by tapping or threading them into holes that have been drilled into my jawbone. I understand that the gum tissue will then be stitched closed over or around the implant to permit healing for a period of 3 to 6 months. I understand that dentures usually cannot be worn during the first few weeks of the healing phase. I understand that the implants placed will be integrated within 3 to 9 months, depending on my personal healing ability.
5. I also understand that during the course of the procedure, unforeseen conditions may arise that necessitate an extension or alteration of the planned procedure contained herein. I therefore authorize and request that the doctor and his associates or assistants under his direction perform such procedure as found necessary and administer such drugs and treatments as required in their professional judgment.
6. I have had the opportunity to discuss with the doctor the planned surgical procedure, implant placement, and my postoperative responsibilities. I understand that following the procedure during the healing process I should not smoke, drink heavily, use any drugs not prescribed by my doctor, should not blow my nose for at least 2 weeks, and thereafter not heavily blow my nose for an additional 2 weeks. I should take any antibiotics prescribed and use pain medication as needed. If I experience an unusual amount of pain, I should contact the doctor or his associates immediately, because it may signify a problem.
7. I understand that anesthesia given during surgery and certain prescription medications used after surgery cause drowsiness and impaired physical performance, and that such effect is increased by the use of alcohol, and that I must not operate a motor vehicle or any other hazardous equipment while taking these drugs. I also agree not to operate a motor vehicle or any other hazardous equipment for at least 48 hours after my release from surgery.
8. I understand no guarantee has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. I also understand that due to individual patient differences and the imperfections of the art and science of surgery, there is a risk of failure or necessity of additional treatment despite />
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