Marys Medicine


Microsoft word - implant consent.docx

Implant Patient Information and Consent Form
1. I understand that dental implant procedures involve a surgical phase (inserting of implants) and a prosthodontics phase (replacing teeth) and that a separate fee is charged for each phase. 2. I understand that after the surgical phase is completed, the completion of my treatment may range from 4-10 months and that additional procedures may extend completion time. 3. I have been informed and I understand the purpose and the nature of the implant surgery procedure. I understand there wil be two planned surgical procedures: 1) opening the gum tissue fol owed by precision dril ing of smal openings into the underlying jaw bone and then the fil ing of these openings with dental implants similar in size to a smal singe tooth root. The gum tissue wil be closed over the implants with sutures (stitches), which wil be removed in 7-14 days. I understand that I cannot wear any denture over the healing implants for at least 2 weeks and that my present denture must be adjusted and/or lined with soft lining before it can be worn. 2) I understand a second surgical procedure 3-6 months after the procedure may be necessary to place implant abutments through the gum. I also understand that the healing of the gum fol owing the second surgical procedure may result in irregularities that may require other surgical corrections that may incur an addition fee (ex. Gum or bone grafts). 4. I hereby authorize J. Travis Kobza, D.D.S. and assistants, to treat the condition(s) described as fol ows: Surgical Procedure(s):


5. Alternatives to this treatment have been explained to me which may include but are not limited to: 1) Continuing with my present denture or not replacing missing teeth; 2) Constructing a new denture without surgical correction or placement of fixed (non-removable) bridge if adequate teeth are available; 3) Constructing a new denture with surgical procedures which may include but are not limited to: moving muscle attachments, nerves, bone or soft tissue grafting. I understand and have considered these alternatives, but I want dental implants to help secure the replacement of tooth or teeth. 6. I understand there are possible risks and side effects involved with surgery, drugs and anesthesia. Such complications my include pain, swel ing, infection, discoloration, numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration of complications may not be determinable and may be irreversible. Also possible are inflammation of vein, injury to teeth present, bone fractures, sinus penetration, delayed healing, al ergic reactions or side effects to drugs or medications used. 7. If you are take bisphosphonate, a drug most often prescribed for osteoporosis, you may be at risk for developing osteoporosis, you may be at risk for developing osteonecrosis of the jaw. Common names of this drug include: Fosomax, Actonel and Boniva. Please ask your provider if you have any questions relative to the risks of these drugs and your procedure. 8. I understand that if no implants are done, any of the fol owing could occur: loss of bone, gum tissue inflammation, infection, tooth or gum sensitivity, looseness and/or drifting teeth, looseness of dentures/bridges and the necessity of tooth extraction. Also possible are temporomandibular joint (jaw) problems, headaches, referred pains to the back of the neck and facial muscles, and tired muscles when chewing. 9. It has been explained to me that there is no method to accurately predict gum and bone-healing capabilities in each patient fol owing the placement of the implant and that in some instances implants fail and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurances as to the outcome or results of treatment or surgery can be 10. If the implant fails to integrate to the bone at or before the second stage procedure (abutment connection) I understand I have the fol owing options: 1) removal of the implant and replacement of a new implant at the proper time. There wil be no surgical fee for this replacement but I wil be responsible for any additional procedures necessary to improve chances of success; 2) removal of the implant and no replacement. Again, know there wil be no surgical fee for the removal of the implant, but there may be additional costs for modification in the planned prosthesis. 11. I understand smoking, alcohol, or improper diet affect gum healing and may limit the success of the implant(s). I agree to fol ow the doctor's hygiene and diet instructions. I agree to report to my doctor for regular examinations as instructed. 12. I have been given an accurate report of my physical and mental health history. I have also reported any prior al ergic or unusual reactions to drugs, food, insect bites, anesthetics, pol ens or dust. 13. I consent to photography; filming and recording of the procedure to be performed for the advancement of implant dentistry provided my identity is not revealed. 14. It has been explained to me that after the completion of healing from the surgical phase (integration of the implants and placements of the abutments) that the fee for the prosthodontics phase is separate in addition to the surgical phase. 15. I have been informed and understand that: a. The design or type of prosthesis (tooth, bridge or denture) may require modification due to the number or final position of the implants b. The prosthesis that attaches to the implants may not look, feel or chew as wel as natural teeth c. Cleaning the implants and prosthesis may be more difficult than natural teeth 16. I understand that I must thoroughly clean my implants and prosthesis as prescribed and that I must have periodic professional cleanings and prosthesis evaluations. Just as can occur with conventional dental work, repairs or replacement may generate additional fees and would be handled on a case-by-case basis. 17. I understand there are two estimated fees for my treatment: 1) Surgical Phase $ 2) Prosthesis Phase $ _ 18. I request and authorize medical/dental services for me, including implants and other surgery. I ful y understand that during and fol owing the contemplated procedure, surgery, or treatment, conditions may become apparent with 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 this is for my best interest. I CERTIFY THAT I READ AND WRITE ENGLISH AND HAVE READ AND FULLY UNDERSTAND THE

Signature of Patient or Responsible Person (Age 19 or Older)


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