APPENDIX F Consent Form for Implant Surgery
The implant surgery procedure has been explained to me, and I understand what is necessary to accomplish the placement of the implant under the gum or in the bone. The Dr./s have carefully examined me. To my knowledge, I have given an accurate report of my health history. Any prior allergic or unusual reactions to drugs, foods, insect bites, anesthetics, pollen, dusts, blood or body disease, gum or skin reactions, abnormal bleeding, or any other conditions concerning my health are included.
I was informed of other methods that would replace missing teeth. I have tried or considered these methods, and I prefer an implant(s) to help secure the replaced missing teeth. I understand that any of the following may occur: bone disease, loss of bone and/or gum tissue, inflammation, swelling, infection, sensitivity, looseness of teeth, followed by necessity of extraction. Also possible are temporomandibular joint problems, headaches, referred pains to the back of the neck and facial muscles, and tired muscles when chewing. I also understand that if conventional removable dentures are used, I may suffer injury to and/or loss of teeth and bone as well.