Instructions To Patient: Please take this document home and read it carefully. Note any questions you might have in the area provided in Paragraph 15. Bring this back to our office at your next appointment and the doctor will review it with you before signing on page 4. 1. My doctor has explained the various types of implants used in dentistry and I have been informed of the alternatives to implant surgery for replacement of my missing teeth. I have also been informed of the foreseeable risks of those alternatives. I understand what procedures are necessary to accomplish the placement of the implant (s) either on, in, or through the bone, and I understand that the most common types of implants available are subperiosteal (on), endosteal (in), and transosteal (through). The implant type recommended for my specific condition is circled above. I also understand that endosteal implants (more commonly known as root form) generally have the most predictable prognosis. I further understand that subperiosteal implants, if an option for me, are not as widely used as root form implants but will negate the necessity of my having the bone grafting and other surgical procedures which would be necessary for the placement of root form implants. I understand that the risk associated with the use of a subperiosteal implant is the failure and loss of the implant which could further reduce the minimal amount of existing bone which I now have, requiring more extensive bone grafting and other surgical procedures at some future time. I also understand that other dental practitioners may not be familiar or experienced in the use of subperiosteal implants, including their placement, maintenance, and treating any problems which might arise involving the subperiosteal implant. I promise to, and accept responsibility for failing to, return to this office for examinations and any recommended treatment, at least every 6 months. My failure to do so, for whatever reason, can jeopardize the clinical success of the implant system. Accordingly, I agree to release and hold my dentist harmless if my implant(s) fail as a result of my not maintaining an ongoing examination and preventive maintenance routine as stated above. 2. 1 have further been informed that if no treatment is elected to replace the missing teeth or existing dentures, the non-treatment risks include, but are not limited to: (a) maintenance of the existing full or partial denture(s) with relines or remakes every three to five years, or as otherwise may be necessary due to slow, but likely, progressive dissolution of the underlying denture-supporting jaw bone; Initial To Consent Library                                                                   Next Page