CONSENT FOR A HYDROXYAPATITE (ARTIFICIAL BONE IMPLANT) Permission is granted to download, print or otherwise copy this form for your personal use. I,______________________ hereby authorize Dr. _____________________ and any other agent or employees of and such assistants as may be selected by him to perform surgery upon me (or upon the person identified below as the patient, for whom I am empowered to consent), to insert a hydroxyapatite implant. I have been informed that I have certain dental conditions or problems which may be treated with a hydrox1yapatite implant. I understand that a hydroxyapatite implant is being recommended to me by Dr. _____________________ and that it will be used to reconstruct my upper and\or lower jaw due to a case of severe bone loss and in order to provide greater stability and improved chewing efficiency. I understand that surgical incision(s) will be made inside my mouth for the purpose of inserting a hydroxyapatite implant in my upper and\or lower jaw. I acknowledge that Dr. _____________________ has explained the procedure, including the number and location of incisions to be made, in detail. I have been informed that it may be possible for me to continue to wear my old denture for a short time after surgery but it will also be necessary for me to get a new dentures at a cost which is not included in the procedure for the placement of the implant. 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 understand that in the event the implant fails during the first post operative year, it will be removed through a second surgical procedure without charge. After that period of time, 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 have been advised and understand that there are alternatives to the use of hydroxyapatite implants, including no treatment at all; placement of regular dentures, the construction of a new standard dental appliance or prosthesis; augmentation of the lower jaw by means of vestibuloplasty(gum surgery), skin and bone grafting, or with synthetic materials; and implantation of another type of device which has been explained to me, including its advantages and disadvantages in addition to cost, and I choose to continue with hydroxyapatite implant recommended by Dr. _____________________. I also authorize and direct Dr. _____________________ to provide such additional services as he or 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 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 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 of_____________________ (if none, put none). Initial_____ To Consent Library                                                                   Next Page