Dental Implant Surgery Informed Consent

1. I have been informed and afforded the time to fully understand  the purpose and the nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone
2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an implant to help secure the replaced 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 lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are Thrombophlebitis (inflammation of the vein), injury to teeth present,bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medications used, etc
4. I understand that if nothing is done any of the following could occur: periodontitis, loss of bone, gum tissue inflammation, infection, sensitivity or looseness of teeth followed by necessity of tooth extraction. Also possible are temporomandibular joint (jaw) problems, headaches or referred pain to the back of the neck and facial muscles,and tired muscles when chewing. In addition, I am aware that if nothing is done, an inability to place implants at a later date due to changes in oral or medical conditions could exist
5. My doctor has explained that there is no method to accurately predict the gum and bone healing capabilities in each patient following the placement of the implant.
6. It has been explained 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 of the results of treatment or surgery can be made. I am aware that there is a risk that the implant may fail, which might require further corrective surgery or the removal of the implant with possible corrective surgery associated with the removal.
7. I understand that excessive smoking, alcohol or blood sugar may affect gum healing and may limit the success of the implant. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.
8. I agree to the type of anesthesia, depending on the choice of the doctor.  I agree not to operate a motor vehicle or hazardous device for at least 24  hours or more or until fully recovered from the effects of the anesthesia or drugs given for my care.
9. To my knowledge, I have given an accurate report of my physical and mental health history.
10. I have also reported any 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.
11. I agree to notify the doctor’s office of any and all changes to my address and/or telephone number within a reasonable time frame (two to four weeks).
12. I consent to photography, filming, recording, x-rays and additional professional staff observing the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed. I authorize the utilization and/or release of all or portions of my dental records or other materials as prepared by Atlas Dental in connection with clinical evaluation, treatment and care, without limitation, for the purpose of sharing the same with other dental practitioners for demonstration, training or other professional scientific purpose.
13. I request and authorize medical /dental services for myself, including  implants and other surgery. I fully understand the contemplated procedure, surgery or treatment conditions that 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 modifications in design, materials or care, if it is felt this is for my best interest. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in addition to or different from that now contemplated, I further authorize and direct my doctor, associate or assistant, to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the implant procedure.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT: