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The purpose of this is to help clarify the
dental implant procedure to patient
I have been informed and understand the purpose and nature of the
implant surgery procedure. I understand what is needed to place the
dental implant. All of my questions have been answered.
Dr. Starkey has carefully examined my mouth. Alternatives to this
treatment have been explained including doing nothing at all. I have
tried or considered these methods. I desire an implant to help secure
artificial teeth.
I have been informed of the risks and possible complications involved
with surgery, drugs, anesthesia. Such complications include pain,
swelling, infection, and discoloration. Numbness of the lip, tongue
chin, cheek, or teeth may occur. The exact duration may not be determinable
and may be irreversible. Also possible are inflammation of a vein,
injury to teeth present, bone fracture, sinus penetration, delayed
healing, allergic reactions to drugs or medications used, etc.
I understand that if nothing is done, any of the following could occur:
bone disease, loss of bone, gum tissue inflammation, infection, sensitivity,
looseness of teeth, followed by necessity of extraction. Also possible
are jaw joint problems, headaches, referred pains to the back of the
neck and facial muscles, and tired muscles when chewing.
Dr. Starkey has explained to me that there is no method to accurately
predict the gum and the bone healing capacities following the placement
of the implant(s).
It has been explained to me that in some instances implants fail and
must be removed. I have been informed and understand the practice
of dentistry is not an exact science; no guarantees or assurance as
to the outcome of results of treatment or surgery can be made. Dr.
Starkey has explained to me that there is no method to accurately
predict the gum and the bone healing capacities following the placement
of the implant(s). It has been explained to me that in some instances
implants fail and must be removed. I have been informed and understand
the practice of dentistry is not an exact science; no guarantees or
assurance as to the outcome of results of treatment or surgery can
be made.
I agree to the type of anesthesia, depending on the choice of Dr.
Starkey. 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.
To my knowledge I have given an accurate report of my physical and
mental health history. I have also reported any prior allergic or
unusual reactions to drugs, food, insects bites, anesthetics, pollens,
dust, blood or body diseases, gum or skin reactions, abnormal bleeding
or any other conditions related to my health.
I consent to photography, filming, recording, and xrays of the procedure
to be performed for the advancement of implant dentistry, provided
my identity is not revealed.
I request and authorize medical/dental services for me, including
implants and other surgery. I fully understand that during, and following
the contemplated procedure, surgery, or treatment, conditions may
become apparent which warrant, in the judgement of Dr. Starkey, additional
or alternative treatment pertinent to the success of the comprehensive
treatment. I also approve any modifications in design material, or
care, if it is felt this is for my best interest.
I understand that regular check ups and cleanings of the dental implants
are needed and they on average vary from three to six month intervals.
In my own words this is what I think Dr. Starkey and team plan on
doing for me
_______________________________________________________.
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Signature of Dr. Starkey
_____________________________
______________________________
Signature of Patient
witness
If patient is unable to sign or is a minor then signature of parent
or guardian:
______________________________
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Date and Relationship to patient
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