DENTAL IMPLANT SURGICAL CONSENT FORM
I____________________, have been informed and understand that transitional or “mini implants” are available to certain dental patients. These mini implants are small titanium alloy dental implant screws that are placed in a patients jaw to provide immediate and on-going stabilization of teeth. I am aware that these implants are being placed for the immediate and on-going stabilization of my dental prosthesis and the long term function can not be predicted. I wish to undergo this procedure as a patient of Dr. McAllister. I have requested Dr McAllister to place one or more mini dental implants into my jaw.
I have also been fully informed by Dr. McAllister that the purpose of this dental implant procedure is to provide support for my lower jaw and to enhance the function, and I hereby consent to the surgical insertion of mini dental implants in my jaw. I understand that in the event that the mini dental implants implanted by Dr. McAllister fail they will be removed through to subsequent surgical procedure. I further understand that it is possible that one or more of the implants may fracture during insertion, or during the implant’s life cycle, and in the event that such a fracture occurs, I give Dr. McAllister permission to leave the fracture in my jaw or to remove it under professional conditions and using professional judgment. It has also been explained to me that once the mini implants are inserted or implanted, to recommended dental treatment plan, including a program of personal oral hygiene must be strictly followed by me and completed on schedule. I have been informed that if this plan and schedule are not carried out, the implants may fail.
I am further aware that the surgical procedure includes the insertion of the mini dental implants into the jaw, and possibly the construction of a prosthetic device. I am aware that I must return for post operative care and evaluation on appropriate to timely basic which will include evaluation of oral hygiene and plaque removal. I also understand that function and comfort will be primary goals of this dental but that success rates of each patient vary procedure. With that in mind, do not guarantees of success have been given to me by Dr. McAllister or any member of this staff. I’ve also informed me that use of tobacco, including cigarette smoking, as well as excessive alcohol consumption can cause failure of dental implants. I have further been advised that swelling, infection, bleeding, and pain may be or associated with any surgical procedure, including the one recommended to me by Dr. McAllister, and said conditions may occur during the life of the implants. I have also been advised that temporary or permanent numbness may occur in my tongue, lips, chin, gum or jaw. Dr. McAllister has discussed the possibility of alternative procedures for my individual needs and has offered to answer any of my questions concerning those procedures.
Having been fully informed of the above, I hereby knowingly consent to the recommended surgical procedures outline to me by Dr. McAllister and request him to place one or more transitional or mini dental implants in my jaw for the purpose of dental reconstruction and enhancement function. I further state that I have carefully read this surgical consent form and understand its contents.
PATIENTS SIGNATURE ___________________________
DOCTORS SIGNATURE DATE
WITNESS SIGNATURE DATE