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Tooth/teeth number(s):

1. I have been informed and I 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 the surgery, drugs and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Also, possible are inflammation of a vein, injury to teeth present, bone fracture, sinus penetration, delayed healing, allergic reactions to drugs or medication used, etc.

4. I understand that if nothing is done, any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth, followed by necessity of extraction. Also possible are temporomandibular joint Uaw) problems, headaches, referred pains to the back of the neck and facial muscles, and sore muscles when chewing.

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. I have been informed and understand that the final esthetic results of the dental restoration may be compromised due to the several factors including bone and/or soft tissue anatomy. I have been advised that additional treatments may be required to improve the esthetic result and that in some cases ideal esthetics may not be possible.

7. It has been explained that in some instances the implants fail and must be removed. I have been informed and understand that there are no guarantees and assurances as to the outcome of results of treatment or surgery can be made.

8. I understand that smoking, alcohol, or 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.

9. 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, anesthetics.

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