The following risks known to be associated with the procedure have been explained to me. These included but are not limited to swelling: infection or abscess; pain: bleeding which may be heavy and prolonged: injury to the 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 which may be permanent; loss of or damage to the ability to taste, speak and/or hear; stretching of the comers of the mouth with resultant cracking or bruising: loosening of the implant because of stress or infection: fracture of the metal or the jaws due to stress. concentration or a blow; and burns from the electrosurgical unit (if such a unit Is used). I understand that any of these treatment complications may necessitate additional recuperation time at home or even in the hospital. Finally, I have been told that this treatment may not be successful and 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 is possible to insert another subperiosteal implant following a suitable healing period. 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 home care 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, anesthetics, pollens, dust, 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 CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATION REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED. I ALSO STATE 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