IMPLANT PATIENT
SURGERY INFORMATION AND CONSENT FORM

1. I,                                                       , authorize Dr.(s)                                                                        and/or such assistants as may be selected by him (them) to provide implant surgery to remedy the conditions or symptoms which appear indicated by the diagnostic studies and/or evaluations already performed and which have been explained to me:                                                       . Explain nature of conditions, e.g., missing teeth or inability to wear previous dentures or patient's desire to use an implant.

2. I also authorize and direct my doctors, with associates or assistants of his (their) choice, to provide such additional services has he (they) may deem reasonable and necessary, including but not limited to, the administration of anesthetic agents; the performance of necessary laboratory, radiological (x-ray) and other diagnostic procedures; the administration of medications orally, by injection, by infusion, or by other dentally accepted routes of administration; and the removal of bone, cartilage, tissue and fluids for diagnostic and therapeutic purposes and the retention or disposal of same in accordance with the usual practices.

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(s), with associates or assistants of his (their) choice, to do whatever he (they) deems necessary and advisable under the circumstances, including the decision not to proceed with the implant procedure.

3. Alternatives to implant surgery have been explained to me, including their risks. I have tried or considered these alternative treatment methods and their risks, but I desire an implant to help secure the replaced missing teeth. I consent to the placement of an implant under the gun or in the bone and I understand the implant surgery procedure.

4. I am aware that the practice of dentistry and dental surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the success of my implant surgery and the associated treatment and procedures. I am aware that there is a risk that the implant surgery may fail, which might require further corrective surgery or the removal of the implant with possible corrective surgery associated with the removal.

5. The implant surgical procedure has been explained to me and I understand the nature of the surgery and anesthetic procedures to be as follows: __________________________

(description in layman terms of the specific implant surgical procedure and anesthetic procedures to be performed.)

6. As with any surgical procedure, there are possible complications of which we feel you must be aware. These include, but are not limited to: limited oral function; post operative pain; bleeding; infection or abscess which may require treatment or drainage; temporary bruising of the face; allergic reactions to medications; a change in sensation or numbness to the lip, chin, gums and/or tongue, which may be of a temporary or permanent nature; an opening between the mouth and sinus which may result in an infection and/or persistent opening requiring other surgical procedures to resolve; injury to the teeth; temporomandibular joint (jaw) problems; and poor healing which may result in loss of the implant. I have also been advised that there is a risk that the implant or crown attached to the implant may break which could require additional procedures including the surgical removal of the implant.

8. I have been advised that excessive use of tobacco, alcohol or sugar may affect gum healing and may limit the success of the implant. Because there is no way to accurately predict gum and bone healing capabilities of each patient, I agree to follow my doctor's home care instructions and to report to my doctor for regular examinations as instructed.

9. I agree not to operate a motor vehicle or hazardous device for at least twenty-four hours or more until fully recovered from the effects of the anesthesia or drugs given for my care as selected by my doctor.

10. To my knowledge, I have given an accurate report of my physical and mental health history. 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 relating to my health or any problems experienced with any prior medical, dental or other health care and treatment. If I am currently in treatment for any health problems, I certify that I have discussed the proposed implant procedure with my health care provider and have received his/her consent to undergo this implant procedure.

11. I fully understand that during and following the contemplated procedure, surgery or treatment, conditions may become apparent which warrant, in the judgment of my doctor(s), additional or alternative treatment pertinent to the success of the comprehensive treatment and therefore authorize such treatment modifications or alternatives as may become necessary in the judgment of my doctor(s).

12. I certify that I have read, have had explained to me, and fully understand the foregoing consent to implant surgery, drug and anesthetic procedure(s), in that it is my intention to have the foregoing carried out as stated. I have been advised that this is a relatively new procedure and that information concerning the longevity of this particular implant to be used is not available. However, I have discussed this, as well as the nature of the implant product to be used, and I consent to the procedure knowing its risks and limitations.