Healthcare Patient Dental Implant Consent Form

Healthcare Patient Dental Implant Consent Form

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Medical History

Please indicate current medical conditions or history that apply (check all that apply):

Pacemaker/ICD Pregnant or planning pregnancy Bleeding disorder/anticoagulants

Diabetes Tobacco use Immunosuppression

Current or prior bisphosphonate use History of cancer/radiation

Procedure Description

I authorize placement of dental implant(s) consisting of endosseous implant fixture(s) and related procedures including any necessary bone grafting, sinus augmentation, and soft tissue management at site(s):

Risks, Complications and Benefits

The expected benefit is the replacement of missing tooth structure to restore function and esthetics. I understand there are risks associated with dental implant therapy. Risks include but are not limited to:

• Pain, swelling, bruising, and infection at the surgical site (may require antibiotics or additional treatment).
• Failure of osseointegration resulting in implant loosening or loss requiring removal and possible replacement.
• Injury or altered sensation to adjacent nerves resulting in numbness, tingling or pain to lip, chin, tongue, or gums which may be temporary or permanent.
• Damage to adjacent teeth, restorations or bone.
• Sinus perforation when treating upper posterior sites, possibly requiring further surgery.
• Need for additional procedures, including bone grafting, soft-tissue grafting, or revision surgery.
• Esthetic concerns including soft-tissue recession and mismatch of color or contour.
• Allergic reaction to implant materials or medications used during treatment.

I acknowledge that no guarantee or assurance has been made by anyone regarding the results that may be obtained.

I have read and understand the risks and complications described above and have had the opportunity to ask questions.

Alternatives

Alternative treatment options were explained to me and may include:

Fixed bridge Removable partial denture No treatment

Anesthesia / Sedation

Type of anesthesia to be used: Local Nitrous Oxide IV Sedation General Anesthesia

I understand that all forms of sedation and anesthesia carry risks including respiratory or cardiac complications, and that I must disclose all medications and medical conditions prior to anesthesia. I consent to anesthesia as indicated above.

I consent to the administration of anesthesia as above and acknowledge instructions regarding fasting, escort requirements, and postoperative care.

Postoperative Care and Responsibilities

I accept responsibility to follow postoperative instructions provided by the dentist or surgical team, including medication regimens, activity restrictions, and follow-up appointments. Failure to follow instructions may increase the risk of complications or implant failure.

HIPAA / Privacy & Authorization

I acknowledge receipt of the practice's privacy practices and consent to the release of my protected health information to other practitioners and insurers for the purpose of treatment, payment, and health care operations as necessary for implant therapy.

Authorization to release implant-related records to referring providers and insurance carriers expires on:

I consent to intraoral photographs and radiographs for diagnosis, treatment planning and recordkeeping.

Consent and Certification

I certify that I have read and understand the information in this consent form, that I have had the opportunity to discuss the procedure, alternatives, risks and benefits with the dentist, and that all of my questions have been answered to my satisfaction. I understand that complications may require additional treatment and that outcomes cannot be guaranteed.

By signing below I voluntarily authorize the dentist and clinical staff to perform the procedure described and any additional procedures deemed necessary in the event of unforeseen circumstances.

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