Dr has examined my mouth and made treatment recommendations to restore my teeth. The risks and benefits of the recommended treatment have been explained to me. Alternative forms of treatment including doing nothing were also explained to me. All of my questions have been answered. I understand that I may seek alternative care to preserve and maintain any teeth that are currently in my mouth. I understand that this alternative treatment may include endodontic, orthodontic, periodontal and/or general dental care. I have elected to have my remaining teeth extracted for the Immediate Load (TeethXpress ) treatment plan with full knowledge of the alternative treatment options. I have considered the alternative forms of treatment with sufficient time and have elected to consent to the TeethXpress Implant-Supported Fixed Bridge procedures for my upper jaw, lower jaw or both. TeethXpress is a surgical procedure and I have been informed about what is involved with placement of the implants and connecting the teeth (bridge(s)). I attest that no guarantees have been made to me about the success of this surgical procedure. I am aware that not following the clinical recommendations of may result in the failure of my implants and/or bridge(s) and I agree to cooperate with my doctor s recommendations and advice prior to and following this procedure.
I have been informed of the possible risks and complications involved with this procedure including the anesthesia and medications used. Complications may include postoperative infection, sinus infection, pain, swelling, and bruising. Numbness of facial structures may occur; the exact duration may not be determinable and in extremely rare cases may be painful and irreversible. It is also possible to have inflammation of jaw joint (TMJ) and veins, bony fractures, penetration of sinus (upper jaw area), allergic reactions, delayed healing, all of which may require follow-up surgery and/ or the possible loss of implants. I have been advised that although the implant is made of biocompatible material, it is a foreign body and may be rejected or poorly tolerated by my body. If rejection occurs, the implant may need to be removed, and, in the event of failure, I have been advised that tissue augmentation may be required to finish my care. I have also been advised and understand that in the event of failure of my implants, the only remaining treatment option is a complete denture. Dr. has informed me that there is no scientific way to predict how my tissues will heal following the placement of dental implants. I agree to follow my doctor s post-operative instructions. I understand that if my implants cannot be loaded with an immediate bridge, I will be provided a denture at no cost to me until the implants heal and the final restoration can be fabricated. I agree to notify Dr. of any problems that may develop during my healing phase.
I am aware that excessive alcohol consumption and the use of any tobacco products effects gum healing and will reduce the success rate of implant healing. I have agreed not to use these products according to the instructions of my doctor. I have been informed that certain medical conditions, including osteoporosis and uncontrolled diabetes may contribute to the failure of dental implants. I have provided a complete medical and dental history to Dr. and will advise him of any changes prior to surgery. I have agreed to see my doctor for all follow up visits and scheduled cleanings after my implants have been placed. I understand that a standard cleaning fee will apply. I have been informed and understand that failure to maintain dental implants can lead to implant failure. I have been informed of the conscious sedation (anesthesia) to be used. I agree not to engage in forms of physical activity and/or operate a motor vehicle for at least twenty-four (24) hours or more until fully recovered from the effects of this sedation. 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 made public without my consent.
I have been encouraged to seek a second opinion if I so desire before consenting to this surgery. I consent to and authorize Dr. to provide the care previously described to me and I understand that during and following the surgery and final treatment procedures, conditions may develop which warrant additional or alternative therapy as determined by the professional judgment of Dr.. I approve any modifications in surgical protocols, and use of restorative materials if it is determined that such changes are in my best interest. I have read and I understand all of the information contained in this consent form for TeethXpress Implant-Supported Fixed Bridge. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns. I hereby consent to the performance of dental implant surgery as presented to me during consultation and in the treatment plan presentation. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of Dr.
Date Parent or Guardian (if patient is a minor) Date Witness Date