Dental Implant Consent

I have been informed and understand that dental implants are available to certain dental patients. These dental implants are Titanium alloy dental implant screws that are placed in a patient’s jaw to provide immediate and on-going stabilisation of teeth. I understand that the alloy contains Titanium, Aluminum and Vanadium. I am aware that these implants are being placed for the restoration of a few missing teeth.

I wish to undergo this procedure as a patient of:

Dentist Name

and I have requested one or more dental implants to be placed into my jaw. My dentist has given me the option of a specialist referral for this procedure. My dentist has also advised me about the possibility of this procedure being done under General Anaesthetic (GA).

I understand that in the event the dental implants implanted by my dentist fail, they may be removed through a subsequent surgical procedure. I further understand that it is possible that one or more of the implants may fail during the healing process. In the instance of any failure within 1 year of the implant being placed, your dentist will refund the entire amount paid for the implant placement other than eight hundred dollars ($800) to cover for the time and materials used. I understand that the dental practice is not responsible for this refund ,the operating dentist will be solely responsible even if the said dentist no longer operates from this dental clinic. It has also been explained to me that once the implants are inserted a recommended dental treatment plan, including a program of personal oral hygiene must be strictly followed by me and completed on schedule.

I am aware that I must return for appropriate post-operative care and evaluation on a timely basis which will include evaluation of oral hygiene, X-rays and plaque removal. I have been informed that if this schedule and plan are not carried out, the implants may fail in the long run. I have also been informed about all surgical complications including the possibility of sinus involvement in the upper jaw. I have also been advised about the possibility of nerve damage caused due to the placement of implants in the lower jaw. My dentist has explained that sometimes we cannot match the gingival outline of implanted teeth to natural teeth. The possibility of alternative procedures for my individual need have been discussed and an offer made to answer any questions with regard to those procedures.

I also understand that function and comfort will be the primary goals of this dental procedure, but that the success rates of each patient vary. I have also been informed that gum disease, use of tobacco, including cigarette smoking and excessive alcohol consumption, can cause the failure of dental implants.

I have further been advised that swelling, infection, bruising, bleeding and/or pain may be associated with any surgical procedure.

I have provided my full medical history and have provided a list of all current medication. I have discussed all the medical conditions which can affect the long-term success of the implants. My dentist has advised me that in the future medications for Osteoporosis can lead to a failure of an integrated implant.

Please indicate below that you understand each bullet point:

Implants are one off many options to replace my missing teeth

Yes

The different prosthetic options have been discussed. I have opted for dental implant retained dentures as I am unhappy with my conventional dentures

Yes

I am aware that gum disease, smoking, uncontrolled diabetes can cause failures of integrated implants and their superstructure

Yes

Implant surgery is invasive and there can be damage to adjacent teeth, nerves (lower implants), floor of the sinus (upper implants).This damage can be reversible or irreversible.

Yes

I will have to maintain these implant prosthesis with regular home hygiene which will be accompanied with hygienist visits and x-rays every three (3) months

Yes

I understand that refunds only apply for a one (1) year period post implant loading. For failures during this period , the practice will hold on to eight hundred ($800) per failed implant and abutment to for its expenses

Yes

I have been advised that this treatment has a success rate of ninety percent (90%) for implant integration and seventy percent (70%) after including prosthetic issues.

Yes

I do not have any history of taking any medications for osteoporosis.

Yes

I have fully disclosed my medical history.

Yes

I have been advised that the superstructure including the dentures might need replacement or repair every five (5) years.

Yes

I have been advised that the substructure or milled bars will need replacement if the implants fail.

Yes

I have been advised that once the try in is complete there will be no further adjustment of the shape and outline of the prosthesis

Yes

There can be a slight leakage or air, change of speech and possible food impaction on the fitting surface of these hybrid restorations.

Yes

I have been given the option to see a specialist for placement of these implants and the fabrication of the prosthesis

Yes

Having been fully informed of the above, I hereby knowingly consent to the recommended surgical procedures outlined to me by my dentist and request him/her to place one or more dental implants in my jaw for the purpose of dental reconstruction and function enhancement.

I further state that I have carefully read this surgical consent form and understand the contents.

First Name

Last Name

Signature

Signed:

Date