Consent Form For Dental Implants

The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents or guardians) to understand and give permission for dental implant treatment. Each item should be initialed after the patients (and/or their parents or guardians) have the opportunity for discussion and questions.

My doctor has explained the nature of my condition to me: missing tooth or teeth. For me to make an informed decision about undergoing a procedure, I should have certain information about the proposed procedure associated with the alternatives and the consequence of not having it. The doctor provided me with this information to my satisfaction. The following is a summary of this information. This form is meant to provide me with the information I need to make a good decision and not meant to alarm me.

After a careful oral examination on and study of my dental condition, the doctor has advised me that my missing tooth may be replaced with artificial teeth supported by an implant. I hereby authorize and direct the doctor and her authorized dental associates to treat my condition.

The procedure I choose to treat is understood by me to be the placement of implants. Additional treatment procedures may include a bone graft, including material of human, animal or plant or origin. The purpose of this procedure is to allow me to have more functioning artificial teeth by the implants providing support, anchorage, and retention for these teeth.

I understand that implant is nonetheless an elective procedure, I have also been advised that any other alternative treatment done for patient in my condition include but are not limited to the bridge partial or full denture or other options. I understand and choose to undergo the placement of implants.

I understand that my gum tissues will surgically be cut open to expose the bone and the implants will be placed immediately by tapping or threading them into holes that have been drilled into my jaw. 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 week of the healing phase. I understand that the Implants placed be integrated in 3 to 9 months’ time, depending on my personal healing ability.

I understand that the course of the procedure, unforeseen conditions may arise that necessitate in extensions or alteration of the planned procedure contained herein, therefore authorize and request at the doctor and her associate or assistance under her direction perform such procedures as found necessary and administer such drugs and treatment as required in their professional judgement.

I have had the opportunity to discuss with the doctor the planned surgical procedure implant placement and my post-operative responsibilities. I understand that following the procedure, during the healing process, I should not smoke, drink, use any drugs not prescribed by my doctor, blow my nose for at least two weeks, and thereafter not heavily blow my nose for an additional two weeks. I should take any antibiotics prescribed and use pain medication as needed. If I experience a usual amount of pain, I should contact the doctor or her associates immediately as it a signify a problem.

I understand the anesthesia given during surgery and certain prescription medications used after surgery cause drowsiness and impaired physical performance, and that such effect is increased using alcohol and that I must not operate, motor vehicle or any other hazardous equipment while taking these drugs. Furthermore, I agree not to operate a motor vehicle or any other hazardous equipment for at least 48 hours after my release from the surgery.

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 exists a risk of failure or necessity of additional treatment despite appropriate care. I have been advised the placement of implants has shown long-term success rates, however, I understand that no such disclosure is not to imply that I personally can expect such a favorable long-term result and that there will be no refund fee from the surgeon or restorative dentist in the event of complications requiring additional surgery to salvage the implant or failure requiring removal of part or all the implant. I further understand that should removal be required of the doctor; she will remove the implant at no additional cost. However, should I elect to have another doctor remove the implant, I am solely responsible for all costs and fees incurred in doing so and hereby release the doctor from any such costs and fees imposed by the other doctor.

I understand that the risks of the surgery include but are not exclusive to:

  • Restricted mouth opening.
  • Gum shrinking.
  • Clicking or pain of the temporomandibular joints (jaw pain)
  • Tooth sensitivity of hot or cold, for days up to months
  • Loose teeth
  • Food lodging between the teeth requiring flossing for removal
  • An unaesthetic exposure of crown margins of teeth
  • Interference with speech sounds
  • Permanent nerve injury possibly requiring nerve graft surgery

I am aware that antibiotics, pain medication and other medications may cause adverse reactions such as redness and swelling of tissues, pain, itching, nausea, vomiting, dizziness coordination. Miscarriage, cardiac arrest, which can be increased by use of alcohol or other drugs, blood clot in the legs, heart, lungs, or brain, low blood pressure, heart attack, stroke, paralysis, and brain damage. After injection, I may have prolonged numbness or irritation in the area of injection. If I use Nitrous Oxide, Atarax, Xanax, Halcion, Versed, Demerol, Fentanyl, or other sedative more risks including but exclusive of passing out, severe shock, stopped breathing, or stopped heartbeat are possible. I will arrange for someone to drive me home in addition and have someone watch me closely for 10 hours after my dental appointment to observe for side effects such as breathing or passing out.

I understand there may be several follow-up clinical visits for the first year following surgery and it is my responsibility to use the doctor at least once a year for a valuation of implant performance and oral hygiene maintenance.

To the best of my knowledge, I have provided an accurate and complete medical and personal history as possible including antibiotics, drugs. medications, and foods to which I am allergic. I will follow all instructions as explained and directed to me and permit all required diagnostic procedures. I have had an opportunity to discuss my past medical and health history including any serious problems or injury with the doctor.

I give permission for persons other than the doctor involved on my care and treatment to observe this operation such as company representatives and dentists who are learning and I consent to photography, filming. recording. and x-rays of my oral and facial structures in the procedure and the publication for educational and scientific purposes provided my identity is not revealed. I give up all rights for compensation for publication of these records.

I know the fee that I am to be charged and I am satisfied with it. I know that it does not include additional postoperative x-rays, injections, or anesthetics that may later be necessary to correct any complications. I have provided all insurance information. if any, however I know some and perhaps all the services provided may not be covered or not considered reasonable and customary to my insurance company and I am responsible for paying all co-pays, deductibles and left services that have not been paid by insurance. I also understand that all accounts not paid in full within 90 days shall accrue interest at the rate of 18%. I will be liable for all collection costs including court costs and attorney fees.

I authorize Dr. Neetu Chopra to perform this procedure listed it in the title but I know that I am free to withdraw from treatment at any time. I also agree I have read and understand all the items listed in the summary above.


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