CONSENT FOR TWO-STAGE ENDOSTEAL OSTEOINTEGRATED IMPLANTS Permission is granted to download, print or otherwise copy this form for your personal use. I,___________________ , hereby authorize Dr. ___________, and any other agents and such assistants as may be selected by him, to perform surgery upon me (or upon the person identified above as the patient, for whom I am empowered to consent), to insert a two-stage endosteal osseointegrated implant(s) in my upper and/or lower jaw. I understand incision(s) will be made inside my mouth for the purpose of placing one or more endosteal titanium root form structures in my jaw(s) to serve as anchor(s) for a missing tooth or teeth or to stabilize a crown(cap), denture or bridge. I acknowledge that Dr. _____________ has explained the procedure, including the number and location of the incisions to be made, in detail. I understand that the crown(cap), denture or bridge will later be attached to this implant by Dr. ___________ and the cost for that work is not included in the charge for this procedure. I also understand that this implant should last for many years, but that no guarantee that it will last for any specific period of time can be or has been given. I have been informed that the implant will remain covered under the gum tissue for at least four months before it can be used and that a second surgical procedure is required to uncover the top of the implant. I also understand that there will be no refund of the fees in the event of failure. It has also been explained to me that once the implant is inserted, the entire dental treatment plan, including my personal oral hygiene, must be followed and completed on schedule. If this schedule is not carried out, the implant may fail. I understand that excessive smoking, alcohol or sugar may effect gum healing and may limit the success of the implant. I agree to follow my doctor's homecare instructions. I agree to report to my doctor for regular examinations as instructed. 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, food, insect bites, dust, pollens, anesthetics, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health. I consent to photography, filming, recording and x-rays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed. I have been informed of the alternatives to use of an osseointegrated implant which may include no treatment at all; construction of a new ridge of my upper or lower jaw by means of vestibuloplasty (plastic surgery on gums), skin and bone grafting with synthetic materials; and implantation of another type of device. The advantages of each of the above procedures, if appropriate, have been explained to me and I choose to proceed with insertion of the osseointegrated implant(s). I also authorize and direct Dr. ___________ to provide such additional services as he may deem reasonable and necessary, including, but not limited to, the administration of anesthetic agents; the performance of necessary laboratory, radiological (x-ray), and other diagnostic procedures; the administration of medications orally, by Initial_____ To Consent Library                                                                   To Next Page