1. I have been informed and fully understand the purpose and nature of implant surgery. I understand what is necessary to accomplish placement of the implant under the gum or in the bone. I authorize medical/dental services for myself, including implants and other surgery.
2. I have been informed that Dr. Hesam Gharib Doust and Hamed Gharib Doust are general dental surgeons. The doctor has carefully examined my mouth. Alternatives to this treatment have been explained. These alternatives are denture(s) and/or fixed bridge(s), or no treatment of any kind. I have tried or considered these methods, but I desire an implant(s) to help secure the replaced missing teeth.
3. I have been informed of possible complications/risks involved with surgery, drugs, and anesthesia. I understand and accept these possible complications/risks. Complications can include, but are not limited to pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration cannot be determined and may be irreversible. Inflammation of the veins, injury to teeth, bone fracture, sinus penetration, delayed healing, allergic reaction to drugs or medications are also possible.
4. I understand if no treatment is completed, any of the following could occur: bone loss, tissue inflammation, infection, sensitivity, loose teeth, could result in extraction. TMJ (jaw) problems, headaches, and referred pain to the back of neck and facial muscles, or tired muscles when chewing. I am aware if treatment is not completed, an inability to place implants in the future due to changes in the oral or medical condition could exist.
5. I am aware it is impossible to predict the ability of the oral cavity to heal following the placement of the implant. Generally, healing time of 3-6 months is normal. There are instances where implant treatment may not succeed. I have been informed and understand that dentistry is not an exact science. No guarantees or assurances regarding results of treatment and surgery can be made. I understand that implants can fail and must be removed. I am aware there is a risk that the implant surgery may fail. This may result in further corrective surgery or the removal of the implant. Alternatives will then be readdressed.
6. I understand that excessive smoking, alcohol use or blood sugar problems may affect gum and bone 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.
7. I agree to the necessary anesthesia required by my doctor. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or until fully recovered from the effects of the anesthesia or drugs given for my care.
8. To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any prior allergies or unusual reactions to drugs, insect bites, anesthetics, pollen, dust, blood or body disease, gum or skin reaction, abnormal bleeding or any other conditions related to my health.
9. I consent to photography, filming, recording, x-rays, and additional professional staff observing the procedure to be performed for the advancement of implants dentistry, provided my identity is not revealed.
10. I fully understand the intended treatment. I approve any modifications in design or material for my best interest. If unforeseen conditions arise during the treatment, I further authorize and direct my doctor to do whatever they deem necessary, including the decision not to proceed with the implant procedure. If prior to, or during surgery, it is determined that there is insufficient bone, I understand that bone grafting will be performed using Mineross or other bone grafting material for an additional fee as previously discussed with me.
11. In rare instances implant treatment fails, including surgery or prosthetics due to biological factors beyond our control or ability to predict. As such, the fee paid is nonrefundable. In these circumstances, we may offer alternative treatment. The patient is still responsible for any material costs incurred with the additional treatment. This in no way implies we have provided inadequate treatment; we desire the best possible outcome for you.
12. There have been recent studies that may link bisphosponate medications with severe bone infections following dental surgery. Examples of this class of medication include Fosomax, Zometa, Didronel, Aredia, Actonel and Boniva. If you are taking any of these medications, please bring this to our attention so that we may discuss how this may impact the proposed surgery.
I certify that I have read and fully understand all the above information and proposed treatment, including possible risks/complications. Signature of consent below.
