of_______________________(if none, put "none"). Prior to performing such additional or different procedures, however, I desire that they be discussed with________________(relationship: __________________) whom I hereby authorize and designate to give consent to treatment on my behalf whenever possible. I agree not to operate a motor vehicle or hazardous device for at least 24 or more hours until fully recovered from the effects of the anesthesia or drugs given for my care. I understand that there are risks associated with this procedure and these have been explained to me. They may include, but are not limited to, swelling; damage to and possible loss of other teeth, fillings or other dental work; infection or abscess; pain; significant bleeding which may be heavy or prolonged; sinus or nasal problems or infection; poor healing; loss of bone; fracture of the jaw; injury to nerves near the treatment site which may cause pain, numbness or tingling of the lips, chin, face, mouth, teeth and tongue (which is usually temporary but may be permanent); loss of or damage to the ability to taste; stretching of the corners of the mouth with resultant cracking and bruising; accidental opening and infection of the normal sinus cavity located above the upper teeth. Although a good cosmetic result is hoped for, it cannot be guaranteed. I also understand that any of these treatment complications may necessitate additional medical, dental or surgical recuperation at home or even in the hospital. Finally, I have been told that this treatment may or may not be successful, that problems may arise during the procedure which may prevent placement of the implant and that rejection of this implant is possible which would necessitate its removal. Should this happen, I understand that it may be possible to insert another implant after a suitable healing period and that a charge will be made for this procedure. 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 CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS REFERRED TO OR MADE AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND THE INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED. I ALSO STATE THAT I READ AND WRITE ENGLISH. Dentist Signature                                   Patient Signature Witness Signature                                 Witness Signature Parent or Guardian, if Patient is a Minor Date: To Consent Library