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 if sedation or general anesthesia is used. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more until fully recovered from the effects of the anesthesia or drugs given for my care. The following risks known to be associated with 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 jaw 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 period or recuperation 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 hydroxyapatite implant following a suitable healing period. 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 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