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Informed Consent Discussion for Implant Placement - Sample form

Patient Name: ______________________________ Date of Birth: _________________  
                                                                                     Date: _______________________

Implant placement and restoration involves two major stages: surgical placement of the implant(s) followed by the restoration of the implant after osseointegration (the bone grows around the implant) has occurred.

Dr. Gary W.D. Lee will be placing the implant(s) which is usually a two stage surgical procedure. A surgical informed consent discussion will take place with the surgeon and your questions will be answered.

Dr. Gary W.D. Lee will be doing the restorative phase and specific questions regarding the prostheses (customized restorations) will be answered during the informed consent discussion.

The following information is an outline of the discussion Dr.Gary W. D. Lee and I had regarding the surgical phase of implant procedure.

Patient's initials Required

______ Patient's condition:

______ Tests, models, stents, and/or x-rays completed:

______ Tests, models, x-rays stents, and/or other procedures to be performed: 

______ Referrals to specialists (if needed): 

A healthy mouth with sufficient bone mass is required for a successful implant result.
______ I may require periodontal disease to be treated and controlled before implant surgery can begin.
______ I may require extractions prior to or after the placement of implants.
______ I may require root canals and crowns to be completed or retreated before implants are placed.
______ I may require bone augmentation or tissue grafts before, during or after implants are placed.
______ I understand that fees for referred treatment(s) are separate and dependant upon the referring dentist's fee schedule.

Alternative Treatment Plans to Implant Placement

Option 1: No Replacement of Missing Teeth

______a. Risks, not limited to the following: Compromised aesthetics and possible drift of adjacent and/or opposing teeth into the space(s) with the resultant collapse of the arch integrity. I understand that if no treatment is elected an inability to place implants at a later date due to changes in oral or medical conditions could occur.
______ b. Benefits, not limited to the following: No additional costs at this time.
______ c. Consequences if no treatment is administered, not limited to the following: I understand that I can choose to do nothing and my present complaints will continue and may worsen. Subsequent choices for repairs may become more difficult, expensive, or not feasible.

Options 2 & 3: Removable or Fixed Appliances
_____ Removable or fixed appliances without implants have been explained to me by Dr. Gary W.D. Lee as an alternative to implant supported restorations. The risks, benefits, and consequences of the two types of appliances were also explained to me and I understood them.

Implant Surgical Treatment Plan

Facts for Consideration
_____ Dental implants are metal anchors placed into the jawbone, underneath the gum tissue, to support artificial teeth where natural teeth are missing. When the bone attaches itself to the implant, these implants act as tooth root substitutes and form a strong foundation to stabilize the customized, artificial teeth.

_____ I understand that the placement of implants and the making of compatible prostheses are two separate treatments with separate expenses and separate risks and benefits.

_____ I understand that in order for the implants to be placed in my bone my gum tissue will be opened to expose the bone. Implants will be placed by pushing or threading them into holes made in the bone.  The implants will have to be snugly fitted and held tightly in place during the healing phase.

_____ I understand that the soft tissue will be sutured closed over or around the implants. A periodontal bandage or dressing may be placed. Healing will be allowed to proceed for a period of three to nine months.

_____ I understand that for those types of implants that require a second surgical procedure, the overlying tissues will be opened at the appropriate time, and the stability of the implant will be tested. If the implant appears satisfactory, an attachment will be connected to the implant. The restorative phase to create a prosthetic appliance or crown(s) can begin.

_____ I understand that no specific estimate can be made regarding the period for the longevity and retention of the implant. If fixtures have to be removed, I should be able to return to using a conventional denture or partial denture or possibly have additional fixtures placed in the future. It has also been explained to me that once the implant is inserted, the entire treatment plan must be followed and completed on schedule. If this schedule is not carried out, the implant(s) may fail.

_____ I understand that additional maintenance and repair may be expected for the implants. I am responsible for all surgical costs after the first year of treatment. I agree to follow pre- and post-operative instructions.

_____ I understand that dentures or removable prostheses usually cannot be worn during the first one to two weeks of the healing phase.

_____ I understand that the practice of dentistry is not an exact science; no guarantees or assurances can be made regarding the outcome or the results of treatment or surgery.

_____ Short term effects after surgery: There may be normal side effects that my surgeon will instruct me how to handle at home, such as: swelling, stiffness of the jaw muscles, bruising, occasional oozing of blood for 24 to 48 hours or moderate pain for 24 to 48 hours.

Patient Name: ______________________________ Date of Birth: _________________ 
                                                                                     Date: _______________________

Risks, Benefits and Alternatives

_____ a. Risks, not limited to the following: Though dental implant surgery has a high rate of success, like all surgery it carries with it the possibility of complications not limited to the following:
• swelling that worsens after 48 hours;
• intense pain that cannot be relieved by prescription medication;
• infection;
• permanent loss or alteration of nerve sensation resulting in numbness or tingling sensation in the lip, tongue, cheek, chin, gums, or teeth;
• sinus complications;
• excessive or prolonged bleeding;
• TMJ (temporomandibular jaw joint) pain or abnormal function of the jaw, jaw fracture;
• adjacent teeth, roots, fillings, or bridgework injuries or damages;
• bone loss around the implant; and
• implant failure (the bone does not grow around the implant).

_____ I understand that if any of the above occurs I must immediately contact my surgeon; who is Dr. Gary W.D. Lee.

_____ b. Benefits, not limited to the following: Increased chewing efficiency and improved appearance or speech are the most common benefits.

_____  c. Consequences of implants and prostheses in the mouth: I understand that smoking, excessive alcohol consumption, chewing hard foods such as ice or hard candy, may result in damage to my implants and can cause them to fail completely.

_____ I understand that a medical condition can compromise the longevity of an implant.
_____ I understand that I must keep my implants and prosthesis clean by daily maintenance as well as regular checkups and cleanings at my dentist's office.

_____ I understand that in addition to the risks and complications associated with implants and prosthetics, certain complications may result from the use of anesthetics or sedatives. The risks, benefits, and alternatives regarding anesthesia will be explained to me, and I will disclose any allergies I have and/or any substances or medications I am taking because they may affect my response to the anesthetic. The dentist administering the anesthetic will conduct a separate discussion with me and require a separate consent afterwards.

Patient Criteria

Almost anybody who is missing teeth can benefit from implant treatment. Those who are experiencing chewing problems and difficulty wearing a removable appliance can look to a restoration anchored to an implant as a possible treatment plan. Those who do not have a disease or condition that interferes with proper healing after implant surgery, i.e., uncontrolled diabetes or radiation/chemotherapy for treating cancer, and who have sufficient bone that is dense enough to secure the implants are possible candidates for an implant treatment plan.
_____ I understand the importance of providing my complete medical history to the dentists who are administering my implant treatment plan. I have reported any known medications, allergies, or prior 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.
_____ I understand that Dr. Gary W.D. Lee may decide to cancel the implant surgery once it is underway if I need supplemental bone grafts or other types of grafts to build up the ridge to allow placement, gum closure, and securing of the implant(s). It may even be discovered once the surgery is underway that I am not a candidate for implant treatment.

□ I have had my questions answered to my satisfaction. I consent to have Dr. Gary W.D. Lee perform the oral surgery to place the necessary implants for my treatment. I authorize and direct this dentist, with his associates, to do whatever they deem necessary and advisable under the circumstances, including not proceeding with the implant procedure once surgery is underway if I am not a candidate for implant treatment.
□  I refuse to give my consent for the proposed treatment(s) as described above and understand the potential consequences associated with this refusal.

_______________________________________________________________________________ Patient's Signature                                                                         Date

I attest that I have discussed the risks, benefits, consequences, and alternatives of implant surgery with (Patient's name), who has had the opportunity to ask questions, and I believe my patient understands what has been explained.


_______________________________________________________________________________ Dentist's Signature                                                                      Date

_______________________________________________________________________________ Witness Signature                                                                        Date

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