Implant Consent Form — Macquarie Fields Dental Care

Please Read Carefully

After a careful oral examination and study of my dental condition, I have been advised by Dr. Deepa Bhardwaj that my missing tooth/teeth may be replaced with artificial teeth supported by dental implants (and supplemental procedures).

ANAESTHESIA

Options include: Local Anaesthetic, Inhalation Sedation (Penthrox), Intravenous Sedation, General Anaesthetic. All risks/benefits and instructions pertaining to sedation and general anaesthesia are on separate forms.

ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

It is a legal requirement that you are given certain information and that we obtain your consent prior to beginning any treatment. You are being asked to sign a confirmation that we have discussed the nature and purpose of the treatment, the known risks associated with the treatment, and the feasible treatment alternatives; that you have been given an opportunity to ask questions and express concerns, and that these have all been answered in a satisfactory manner. Please be sure to read this form carefully before signing it and ask about anything that you do not understand.

CONSENT FOR DENTAL IMPLANT/S

I hereby authorise and direct the provider with associates and/or assistants of his or her choice to perform the proposed surgery upon me, or on my dependant (of whom I have legal guardianship of and/or are legally empowered to give consent for) to insert dental implant(s) in my upper and/or lower jaw and/or placement of bone graft as necessary.

SURGICAL PHASE OF PROCEDURE

I understand that a local anaesthetic will be administered to me as part of the treatment. My gum tissue will be opened to expose the bone, implants will be placed and the gum sutured during the healing phase.

I understand that the healing phase of surgery varies from patient to patient but typically lasts between 2–6 months (or more when bone grafts or sinus elevation are concerned). I understand that dentures or partial dentures that place pressure on the surgical site are to be avoided for 1–2 weeks following surgery unless instructed otherwise.

After a careful oral examination and study of my dental condition, I have been advised by Dr. Deepa Bhardwaj that my missing tooth/teeth may be replaced with artificial teeth supported by dental implants (and supplemental procedures).

ANAESTHESIA:
Options include: Local Anaesthetic, Inhalation Sedation (Penthrox), Intravenous Sedation, General Anaesthetic. All risks/benefits and instructions pertaining to sedation and general anaesthesia on separate forms.

ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION:
It is a legal requirement that you are given certain information and that we obtain your consent prior to beginning any treatment. You are being asked to sign a confirmation that we have discussed the nature and purpose of the treatment, the known risks associated with the treatment, and the feasible treatment alternatives; that you have been given an opportunity to ask questions and express concerns, and that these have all been answered in a satisfactory manner. Please be sure to read this form carefully before signing it and ask about anything that you do not understand. We will be more than happy to help as much as possible.

CONSENT FOR DENTAL IMPLANT/S:
I hereby authorise and direct the provider whose name appears above with associates and/or assistants of his or her choice to perform the proposed surgery upon me, or on my dependant (of whom I have legal guardianship of and/or are legally empowered to give consent for) to insert dental implant(s) in my upper and/or lower jaw and/or placement of bone graft as necessary.

SURGICAL PHASE OF PROCEDURE:
I understand that a local anaesthetic will be administered to me as part of the treatment. My gum tissue will be opened to expose the bone, implants will be placed and the gum sutured during the healing phase.

I understand that the healing phase of surgery (that is, until the implants bare integrated with the bone and ready for loading) varies from patient to patient and case to case, but typically lasts between 2-6 months (or more when bone grafts or sinus elevation are concerned). I understand that dentures or partial dentures that place pressure on the surgical site are to be avoided for 1-2 weeks following surgery unless instructed otherwise. If an immediate restoration is placed over the implant(s), it is important that touch and pressure on the region is minimised during the healing phase.

Risks, Alternatives & Follow-up Care

EXPECTED BENEFITS

The purpose of dental implants is to allow me to have more functional artificial teeth and an improved appearance. The implants provide support, anchorage, and retention for the artificial tooth replacement.

PRINCIPAL RISKS AND COMPLICATIONS

I understand that a small number of patients do not respond successfully to implant placement. Complications include but are not limited to:

Post-surgical infection, bleeding, swelling, pain and facial discolouration
Cracking or bruising of the corners of the mouth
Transient but rarely permanent numbness of the jaw, lip, tongue, teeth, chin or gum
Restricted ability to open the mouth for several days
Jaw joint injuries or associated muscle spasm
Inflammation or infection of the sinuses (where grafts or implants to the upper jaw are concerned)
Tooth sensitivity to hot, cold, sweet or acidic foods
Shrinkage of the gum upon healing resulting in elongation of some teeth
Impact on speech; allergic reactions; accidental swallowing of foreign matter

ALTERNATIVES TO SUGGESTED TREATMENT

I understand that alternatives to dental implant surgery include: no treatment, removable prosthesis, fixed prosthesis and other procedures depending on circumstances.

NECESSARY FOLLOW UP CARE AND SELF CARE

I understand that it is important for me to continue to see my regular dentist. Implants, natural teeth and appliances must be maintained daily in a clean and hygienic manner. I understand that smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery.

NO WARRANTY OR GUARANTEE

Although the likelihood of success is extremely high, I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful.

SMOKING

It is advised that smoking be ceased for as long as possible in the weeks surrounding the surgery — preferably 3 weeks before and 4 weeks after. Smoking can seriously impede healing and integration of dental implants and bone/sinus grafts.

EXPECTED BENEFITS:
The purpose of dental implants is to allow me to have more functional artificial teeth and an improved appearance. The implants provide support, anchorage, and retention for the artificial tooth replacement.

PRINCIPAL RISKS AND COMPLICATIONS:
I understand that a small number of patients do not respond successfully to implant placement. In such cases, implants may have to be removed and replaced. Because each patient's conditions are unique, long term success may not occur for every case.

I understand that complications may result from the implant surgery, drugs or anaesthetics. These complications include but are not limited to:
- Post-surgical infection, bleeding, swelling, pain and facial discolouration
- Cracking or bruising of the corners of the mouth
- Transient but rarely permanent numbness of the jaw, lip, tongue, teeth, chin or gum. This can be due to the proximity of nerves to the surgical site, though this risk is low.
- Restricted ability to open the mouth for several days
- Jaw joint injuries or associated muscle spasm
- Transient but rarely permanent increased tooth looseness
- Inflammation or infection of the sinuses (where grafts or implants to the upper jaw are concerned)
- Tooth sensitivity to hot, cold, sweet or acidic foods
- Shrinkage of the gum upon healing resulting in elongation of some teeth and greater spaces between some teeth
- Impact on speech
- Allergic reactions
- Accidental swallowing of foreign matter
- The exact duration of any complications cannot be determined and they may be irreversible.

There is no method that will accurately predict or evaluate how the gum and bone will heal. I understand that there may be a need for a revision procedure if the initial result is not satisfactory. In addition, the success of dental implants can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene and medications that I may be taking. To my knowledge, I have reported any prior drug reactions, allergies, diseases, symptoms, habits and conditions which might in any way relate to this surgical procedure.

ALTERNATIVES TO SUGGESTED TREATMENT:
I understand that alternatives to dental implant surgery include: no treatment, removable prosthesis, fixed prosthesis and other procedures depending on circumstances. However, I further understand that continued wearing of ill-fitting appliances or leaving the site without implants can result in further damage to the bone and soft tissue of my mouth and face, and may also diminish my eligibility for dental implant treatment in the future.

NECESSARY FOLLOW UP CARE AND SELF CARE:
I understand that it is important for me to continue to see my regular dentist. Implants, natural teeth and appliances must be maintained daily in a clean and hygienic manner. Implants and appliances should be examined by your referring dentist or Dr. Deepa Bhardwaj periodically. I understand that failure to follow such recommendations could lead to ill effects, which would become my sole responsibility. I understand that smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery.

NO WARRANTY OR GUARANTEE:
Although the likelihood of success is extremely high, I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. Due to individual patient differences, Dr Deepa Bhardwaj cannot predict certainty of success. There is a risk of failure, relapse, additional treatment or even worsening of my dental implants and surrounding teeth, including the possible loss of certain teeth or implants, despite the best care.

SMOKING:
It is advised that smoking be ceased for as long as possible in the weeks surrounding the surgery preferably 3 weeks before and 4 weeks after. Smoking can seriously impede healing and integration of dental implants and bone/sinus grafts.

Patient Details

First Name *

Last Name *

Mobile *

Total Cost ($)

First Visit Cost ($)

Declaration

Date *

Patient or Legal Guardian Signature *

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Macquarie Fields Dental Care