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7. I have also been advised that there is a risk that the implant may break, which may
require additional procedures to repair or replace the broken implant.
8. I authorize my dentist to perform dental services for me, including implants and other
related surgery such as bone augmentation. I agree to the type of anesthesia that he/she has discussed with me,
circled below, and their potential sides effects, specifically (local) (IV sedation) or (general). I agree not
to operate a motor vehicle or hazardous device for at least twenty-four (24) hours or more until fully recovered
from the effects of the anesthesia or drugs given for my care. My dentist has also discussed the various kinds
and types of bone augmentation material, and I have authorized him/her to select the material which he/she believes
to be the best choice for my implant treatment.
9. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in
addition to or different from that now contemplated and I am under general anesthesia or I.V. sedation, I further
authorize and direct my dentist, his/her associates or assistants of his/her choice, to do whatever he/she/they
deem necessary and advisable under the circumstances, including the decision not to proceed with the implant procedure(s).
10. I approve any reasonable modifications in design, materials, or surgical procedures, if my dentist, in his/her
professional judgment, decides it is in my best interest to do so.
11. To my knowledge, I have given an accurate report of my health history. I have also reported any past allergic
or other reactions to drugs, food, insect bites, anesthetics, pollens, dust; blood diseases, gum or skin reactions,
abnormal bleeding or any other condition relating to my physical or mental health or any problems experienced with
any prior medical, dental or other health care treatment on my medical history questionnaire. I understand that
certain mental and/or emotional disorders may contraindicate implant therapy and have therefore expressly circled
either YES or NO to indicate whether or not I have had any past treatment or therapy of any kind or type for any
mental or emotional condition.
12. I authorize my dentist to make photos, slides, x-rays or any other visual aids of my treatment to be used for
the advancement of implant dentistry in any manner my dentist deems appropriate. However, no photographs or other
records which identify me will be used without my express written consent.
13. I realize and understand that the purpose of this document is to evidence the fact that I am knowingly consenting
to the implant procedures recommended by my dentist.
14. I agree that if I do not follow my dentist's recommendations and advice for post-operative care, my dentist
may terminate the dentist-patient relationship, requiring me to seek treatment from another dentist. I realize
that post-operative care and maintenance treatment
Initial_____
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