1. I have been informed and I understand the purpose and the nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of implants.
2. My mouth has been examined and alternatives to implant treatment have been explained. I have tried or considered these methods, but I desire implant(s) to help support the replacements for missing teeth.
3. I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lips, tongue, chin, cheeks, or teeth may occur and the exact duration may be brief or may be irreversible.
4. It has been explained to me that there is not method to accurately predict the gum and bone healing capabilities in each patient following the placement of an implant.
5. It has been explained that in some instances implants fail and must be removed. I have been informed and understand the practice of dentistry is not an exact science; no guarantees or assurance as to your body’s response to treatment or surgery can be made or implied.
6. I understand that smoking or alcohol may effect gum healing and may limit the success of the implant.
7. I agree to the type of anesthesia as recommended by the surgeon. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more until fully recovered from the effects of the anesthesia or drugs given for my care.
8. To my knowledge I have given an accurate report of my physical and mental health history. I have also reported and prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.
9. I consent to photography, filming, recording, and x-rays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed.
10. I request and authorize medical/dental services for me, including implants and related surgery to include possible soft tissue grafting, and nerve repositioning. 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.
11. I understand that the short and long term success of any health treatment depends heavily on maintenance care. I therefore agree that I will follow instruction in home care of my mouth, will avail myself to all necessary follow up care and subsequent treatment requirements including regular examinations as instructed.
12. I understand that with declining health, aging and inability to seek care and provide care that my implant rehabilitation may eventually have to be modified or may even fail.