What you are being asked to sign is a confirmation that we have discussed the nature, cost and purpose of implant treatment, the known risks associated with implant treatment, the feasible treatment alternatives, that you have been given the opportunity to ask questions and all your questions have been answered in a satisfactory manner, to your understanding. Please read this form carefully before signing it and ask about anything that you do not understand.
Acknowledgment:
1. I have been informed and understand the purpose and the nature of the implant surgery procedure. I understand the procedure that is necessary to accomplish the placement of the implant in the bone. I also understand that upon entering the surgical site, it may be determined that the implant placement is not possible.
2. I understand that the dentist has carefully examined my mouth. Alternatives to implant treatment have been explained to me, namely dentures, bridgework or leaving the space. I have tried or considered these methods, but desire implant treatment to help secure the replacement restoration(s) for my missing tooth/teeth.
3. I have been informed of the possible risks and complications involved with implant restorations that include but are not limited to the following: recession of the gum around the implant or adjacent teeth, implant fracture, screw loosening or fracture, acrylic or porcelain fracture or cement failure.
4. I have been informed of the possible risks following surgical procedures – pain or discomfort, swelling, bruising, bleeding (haematoma) or infection but with careful technique and medication these can be kept to a minimum. I have also been informed of the risks of damage to adjacent structures such as teeth, nerves or blood vessels. There is a slightly increased risk of nerve damage where implants are placed in the lower jaw. These nerves are called the ‘Inferior Dental’, ‘Long Buccal’, ‘Lingual’ and ‘Mental’ nerves.
5. There may be some minor scarring of the gum but with time this will fade. The gum around adjacent teeth/crowns/veneers/bridgework may recede slightly as part of the natural healing process. This may lead to additional treatment being required or crowns/bridgework, which appear slightly longer.
6. The clinician has explained that there is no method to accurately predict the gum and bone healing capabilities in each patient following tooth extraction or the placement of the implant. If there is inadequate bone or gum tissue, there may be a need for additional treatment. This is in the form of grafting procedures. These can cost between £250 and £950 per procedure, should these be necessary, additional consent procedures and estimates may be required.
7. It has been explained to me that in a small number of cases (<5%) implants fail and need to be removed. In most cases a new implant can be placed after a sufficient healing period. All treatment is guaranteed for a period of 12 months from the date of the implant placement. This guarantee excludes trauma or neglect of the implant and requires the patient to attend for regular examinations every 6 months.
8. I understand that excessive smoking (more than 5 cigarettes a day or equivalent) may affect gum healing and may limit the success of the implant. I accept that if I continue to smoke during treatment I will be charged for each replacement implant should there be a failure of one or more of them.
9. I agree to follow the home care instructions provided to me. I agree to maintain my regular examinations as required.
10. I understand that x-rays will be taken before, during and after treatment. A number of x-rays are required during the course of the implant therapy and that every situation is different. In complex cases it may be necessary for a CT scan.
11. I understand that I may not have sufficient bone for the placement of implants. I consent to the use of grafting materials in an attempt to create more bone. These materials may include products derived from animals (see additional consent form) or are synthetic.
12. To my knowledge, I have given an accurate report of my physical and mental health history. I have reported any prior allergic or unusual reactions to drugs, food, insect bites, anaesthetics, pollen, dust, latex, any blood or body diseases, gum or skin reactions, abnormal bleeding or any other condition related to my health.
13. I consent to photography, study models and X-rays of the procedure to be performed. Some of these records may be used for the purposes of teaching, marketing or in case presentations. I understand that my name/identity will not be disclosed in these situations without prior written consent.
14. I consent to details of my implant treatment being kept for the purpose of audit.
15. I understand that with any dental treatment, my teeth, gums or bone can be damaged by plaque, calculus (tartar) or bacteria and I must do my utmost to remove the plaque off all surfaces of all my teeth, restorations and/or implants every day. If I do not clean my teeth and/or implants properly, I may get decay and/or gum disease and my treatment/implants may fail.
– I have been fully informed of the nature of implants and implant surgery.
– I am aware of the risks and complications of implant treatment.
– I have been informed of the alternatives to implant treatment.
– I have read the above form fully, understand its contents and hereby consent to treatment.