CONSENT FOR ENDOSTEAL BLADE IMPLANTS Permission is granted to download, print or otherwise copy this form for your personal use. I hereby authorize Dr. __________, and any other agents or employees of and such assistants as may be selected by any of them, to perform surgery upon me (or upon the person identified below as the patient, for whom I am empowered to consent), to insert an endosteal blade 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 blade implant(s) 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), bridge or denture will be attached to this\these implant(s) and the cost for that treatment 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(s) must remain covered under the gum tissue for at least three 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, examinations and professional cleanings must be followed and completed on schedule. If this schedule is not carried out, the implant may fail. I have been informed of the alternatives to the use of a blade implant, including no treatment at all; construction of a new upper or lower jaw by means of vestibuloplasty (plastic surgery on gums), skin and bone grafting or with synthetic materials; and implantation of another type of device. The advantages and disadvantages of each of the above procedures have been explained to me and I choose to proceed with insertion of the blade implant. I also authorize and direct Dr. ______________ to provide 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 injection, by infusion, or by other medically accepted route of administration; and the removal of bone, soft tissue and fluids for diagnostic and therapeutic purposes and the retention or disposal of same in accordance with usual practices. If any 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 any form of sedation or anesthesia, I further authorize and direct whatever is deemed necessary and advisable under the circumstances with the exception Initial_____ To Consent Library                                                                   Next Page