CONSENT FOR A SUBPERIOSTEAL IMPLANT Permission is granted to download, print or otherwise copy this form for your personal use. I,_______________________________ , hereby authorize and direct 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 above as the patient, for whom I am empowered to consent), to insert a subperiosteal Implant. I have been informed that I have certain dental conditions or problems which may be treated with a subperiosteal implant. I understand that a subperiosteal implant is being recommended to me by Dr. _____________________ and that it is necessary to reconstruct my upper/lowerjaw due to severe bone loss and in order to provide greater stability and improved chewing efficiency. I understand that surgical inclusion(s) will be made inside my mouth for the purpose for inserting the implant on my upper/lowerjaw. I acknowledge that Dr. _____________________ has explained the procedure, including the number and location of incisions to be made, in detail. I also understand that this implant should last many years but no guarantee that it will last for any specific period of time can be or has been given. I understand that in the event the implant falls, it will be removed through a second surgical procedure and that there will be no refund of the fees in the event of failure. It has been explained to me that the entire 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. Dr. _____________________ has carefully examined my mouth. I have been advised and understand that there are alternatives to the use of dental implants, including no treatment at all, the construction of a new standard dental appliance or prosthesis, and augmentation of the upper/lower jaw by means of vestibuloplasty (gum surgery) and skin or bone grafting and I choose to continue with the subperiosteal implant recommended by Dr. _____________________. I understand that if nothing is done any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection and sensitivity. looseness of teeth followed by the necessity of extraction. Also possible are temporomandibular joint (jaw) problems, headaches referred pains to the back of the neck and facial muscles and tired facial muscles when chewing. I also authorize and direct Dr. _____________________ to provide such additional services as he or they 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 medication orally, by injection, by infusion or by other medically accepted routes of administration and the removal of bone, tissue and fluids for diagnostic and therapeutic purposes and the retention or disposal of same in accordance with usual practice. If any unforeseen condition arises In the course of treatment which calls for the performance of additional procedures, and I am under any form of sedation or anesthetic, I further authorize and direct whatever is deemed necessary and advisable under the circumstances with the exception 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 designation to give consent to treatment on my behalf whenever possible. If sedation or general anesthesia is used, 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. Initial_____ To Consent Library                                                                   Next Page