DENTAL IMPLANT CONSENT FORM (PLUS CONSENT FOR ANESTHESIA AND BONE GRAFT PLACEMENT)

Information for dentist regarding dental implant consent form

This document contains a free to download and use dental implant consent form. The form is provided complimentary for use by dentists, oral surgeons or other dental specialists. It is provided courtesy of dentaldecider.com. The document can be downloaded as a pdf file or if you prefer simply edit and paste directly off of our website.

Guidelines for using dental implant consent form

All of our consent forms are free to download and use for dentists and dental specialists. You have the option of downloading the pdf file and directly using it as is. Or you can copy, paste this document and make appropriate changes better suit your needs.

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If you have any suggestions to improve our consent forms please email customer service at customerservice@dentaldecider.com. We would great appreciate it! Good luck and enjoy dear colleagues.

DENTAL IMPLANT CONSENT FORM (PLUS CONSENT FOR ANESTHESIA AND BONE GRAFT PLACEMENT)

presented by dentaldecider.com in conjunction with Toothy Lane

This is an informed consent form to better inform patients of risks and benefits associated with dental implant placement surgery. First, it discusses risks and benefits of anesthesia and sedation prior to placing the dental implant. Next it discusses the pros and cons or a placing bone graft along with your dental implant (if indicated). Finally, it discusses the benefits and risks of placing dental implants. Please read carefully and initial and sign where indicated. If you have any questions please ask your dentist before signing off on this consent form.

TEETH NUMBER(S) CORRESPONDING TO DENTAL IMPLANT PLACEMENT:

Teeth number(s): _____________________________________________

Patient initial: _________

ANESTHESIA CONSENT

____________ (patient initial) I understand that my dentist will be using local anesthetic along with epinephrine to numb up my mouth prior to placing dental implant(s). I am aware of the risks and complications that are associated with using local anesthetics along with epinephrine. Risks include pain, allergic reaction, hematoma, elevated blood pressure, dizziness, fainting as well as anaphylactic shock (in rare cases).

Additionally, I have also been made aware of various methods to relieve anxiety prior to dental implant placement surgery. I hereby consent to the following form of sedation being used in conjunction to local anesthetics (please initial next to your preferred option if any):

_________ Nitrous Oxide which involves inhaling nitrous oxide gas during surgery. Risks include nauseousness, vomiting, dizziness in addition to risks of local anesthetic.

_________ Pre-medication with anti-anxiety medication which involves taking one or a few anti-anxiety pills prior to surgery. Risks include severe disorientation, excessively long lasting effects, overdose which can result in death in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

_________ Intravenous (IV) Sedation which involves injection of drugs into the arm to achieve a higher level of disorientation known as deep sedation. Risks include agitation, ineffectiveness, overdose which can result in breathing suppression and possibly morbidity in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

_________ General Anesthesia which is the highest level of sedation and can only be performed within the operating room in a hospital setting. Risks include prolonged disorientation and overdose which can result in breathing suppression and possibly morbidity in addition to risks of local anesthetic. I also understand that sedation may cause drowsiness and impair my awareness and coordination. As such I will not be operating a motor vehicle or any other hazardous devices before achieving full recovery.

BONE GRAFT PLACEMENT CONSENT

____________ (patient initial) I understand that often times bone graft is required for successful placement of dental implants. I have also been made aware if bone graft is necessary in conjunction to dental implant placement in my case. My dentist or dental staff have explained to me how bone graft is made and placed. I have read and understand the risks and benefits of using bone graft after tooth removal.

BENEFITS OF BONE GRAFT PLACEMENT
  • I understand that a bone graft is highly recommended if I want to allow better healing and osseointegration of dental implants.
  • I understand that placing bone graft usually helps expedite the healing process and success rate of dental implants.
  • I understand that without bone graft my chances of my dental implant healing properly decreases.
RISKS OF BONE GRAFT PLACEMENT
  • I understand that placing bone graft along with dental implant placement is not always mandatory. However, often times it is required.

  • I understand that bone graft may become dislodged and not be as effective.
  • I have been made aware if there are costs associated with placing a bone graft.
  • I understand that placing a bone graft will not in anyway prevent or reduce the risks and complications associated with dental implant placement surgery.

Having read the benefits and risks of placing a bone graft, please initial next to your preferred option:

____________  I agree to place bone graft along with my dental implant

____________  I reject placing bone graft at my own risk

DENTAL IMPLANT PLACEMENT CONSENT

____________ (patient initial) I am willingly and consciously giving my dentist informed consent to have dental implants placed into my mouth. I have already been informed about success rates of dental implants. I understand that while success rates are high, dental implants may still fail. This usually requires removal of the dental implant, placement of bone graft and redoing the entire procedure. However, I still would like to proceed with dental implant placement with the full understanding of risks and possibility of failure.

DENTAL IMPLANT CONSENT

____________ (patient initial) I am willingly and consciously giving my dentist informed consent to have dental implants placed into my mouth. I understand that there are certain risks associated with this procedure. I understand that there are alternative treatment options such as a dental bridge, dentures or simply leaving the site untreated. However, I choose to place dental implants over all alternative treatment options.

BENEFITS OF DENTAL IMPLANT PLACEMENT
  • Replaces missing teeth to improve chewing, speech and appearance
  • Prevents remaining teeth from shifting into missing space
  • Gives you the equivalent of a missing tooth without causing damage to adjacent teeth
RISKS OF DENTAL IMPLANT PLACEMENT
  • Implant failure to integrate with your jawbone. If your implant fails it must be removed, much like a tooth extraction. Before attempting to place a second dental implant, the area needs to be prepared again with bone again and allowed to sufficiently heal. This may possibly require an additional surgical procedures to better prepare your bone for receiving the dental implant. This is a long, drawn-out process which can delay your implant placement process by as much as one year or longer.
  • Pain after implant placement. While dental implants are typically not as painful as teeth extractions, since you are not dealing with actual teeth, they may still cause pain and swelling for several days.
  • Infection, swelling and bruising of the surgery site. Taking antibiotics can help but it might not fully eliminate your problem.
  • Excessive bleeding after being dismissed from your implant surgery. While we try our best to get bleeding under control before dismissing you, this doesn’t always work. You must carefully follow post-operative instructions to help get bleeding levels under control. However if you get home and bleeding doesn’t stop, then you must contact your dentist immediately or otherwise go to an emergency room for further treatment.
  • Drug reactions and side effects to the medications used or those given to aid in the recovery process.
  • Difficulty eating, chewing or even breathing for a while after your surgery.
  • Accidental damage to the rest of your oral region. This can include laceration to your tongue, stretching of corners of mouth, cheek bruising and other traumas.
  • Accidental damage to adjacent teeth, particularly if these teeth already have a filling or crown. If adjacent teeth sustain any damage this will require additional dental work. Unfortunately, your dentist can not be held responsible for this and you have to fix these problems later at your own expense.
  • Jaw problems (Temporomandibular Joint or TMJ) known as Trismus. TMJ problems include limited opening of your jaws and soreness in the region. These symptoms may alleviate gradually over the course of a few months or they may be indefinite. Follow instructions and followup with your dentist for quicker recovery.
  • Possibility of dental implant infringing on your jaw nerves. This may result in temporary or possibly permanent tingling or numbness, or pain of the lip, chin or tongue on the operated side. This may require the removal of the implant. Implant removal may or may not reverse the numbness effects.
  • Possibilty of dental implant damaging your sinus membrane. This may occur during the placement of implants in the upper posterior jaw region. Sinus membrane damage may heal on its own or it may require additional treatment or surgical repair at a later date to repair.  On occasions, you will be required to remove your dental implant as well.
  • Failure of dental implant may lead to infection involving the bone  and cause osteomyelitis. While rare, this can cause extensive damage and  but may require aggressive treatment, including, but not limited to, hospitalization which causes you to incur considerable additional expenses.
  • While extremely rare, jaw fracture can also occur as a result of dental implant placement. This will require additional surgery(s) and possibly require wiring your mouth shut for an extend period of time.
  • Additional unpredictable followup surgeries may be indicated.

I consent that I have thoroughly read and fully understand everything listed above. I understand that dentistry is not an exact science and that there are no guaranteed results. Additionally, I have asked any other questions and have received a satisfactory answer. I am prepared to have my dental implant placed with the full understanding of all possible risks and complications associated with this surgery.

Patient name: ______________________________________

If minor, guardian name: ____________________________________

Relationship to patient (minors only): ____________________________

Patient (or legal guardian) signature: ____________________________

Date : ________________

Witness name: _________________________________________________

 Witness signature: __________________________________________________

Date : ________________

 

Doctor name: ____________________________________________________  

Doctor signature: __________________________________________________

Date : ________________

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