CONSENT

If you have any questions about this form, please ask the dentist before signing it.

Dental surgeon proposing the implant treatment plan has carried out detailed examination of my teeth and periodontal status and explained to me the findings and treatment needs.

I have read and understood the above information and discussed in detail the procedure, risks, benefits, options and long-term care needs related to implant based dental restorations.

I have considered all alternatives carefully.

All my questions related to implant treatment have been answered to satisfaction.

I give consent to carry out • Examination and investigations • Surgical placement of dental implants • Additional procedures as soft tissue surgery and grafts • Restoration using dental implants • Photography, filming and radiographs to be recorded and used for educational purposes.

I agree to follow all home care instructions given to me by the dentist. To the best of my knowledge I have given an accurate history about my health, medications and allergies.

I understand the importance of regular maintenance visits following implant treatment to ensure long and healthy life of implants.

I will seek regular implant checkup appointments with my dental practitioner or dentist providing the restorative treatment. •

I have asked all relevant questions related to my treatment and I am satisfied with explanation. •

I have received a definitive treatment plan and all other alternate options available in writing and have considered the options carefully. •

I have received in writing, the cost of my treatment, both for surgical and restorative stages.

I agree to pay the fees as per schedule. • I have understood the approximate time needed to complete this treatment process.

INFORMED CONSENT FOR BONE GRAFTING SURGERY

The bone grafting procedure involves opening the gums in the area to expose the existing bone.

This is then followed by placing bone material in such a manner so as to augment the existing bone. A protective barrier or membrane is then placed over the grafted bone for protection. The gums are then closed over and sutured (stitched) in place to completely cover the bone grafted area.

A healing time of 4-6 months is then typically allowed for the bone graft to “take”, mature, and integrate with the surrounding native bone. As discussed, the bone graft material and membrane we’ll be using is derived from a donor source (synthetic or animal).

The materials I use have been documented to be safe and reliable. If you agree to have implants without risks and costs associated with bone graft, this may affect the position of the implants and cause some esthetic compromise in the end result of the restoration.

The purpose of bone grafting in your case would be to increase the width of the existing bone to allow for proper implant placement. It would also help to harmonize the esthetics of the region. Principal Risks and Complications Although bone grafting of localized areas to increase the width of existing bone has been shown in clinical studies to be a predictable procedure, a very small number of patients do not respond successfully to the procedure and may require revision procedures to attain the desired result.

The procedure may not be successful in preserving function or appearance. Because each patient's condition is unique, long- term success may not occur. Complications may result from grafting surgery, drugs, or local anesthetics. The exact duration of any complications cannot be determined and they may be irreversible.

Treatment Completion Declaration

I have received the implant placement and restoration as discussed in the above consent form.

I am satisfied with the functional and cosmetic outcome of the work carried out.

Where applicable I have been offered advice and options to change the treatment plan, and was involved in the process of decision making fully.

I also agree to abide by the conditions regarding long term care of the implants and the restorations provided to me. This will include regular dental and hygiene visits and meticulous home care. I have received demonstration of long-term hygiene care of the implants.

I understand that continued or new risk factors like smoking will shorten the life of successful integrated implants.

I have made aware that habit of clenching and grinding teeth may cause damage to the implant and restoration provided.

If I am advised of such diagnosis, I will seek appropriate treatment to protect the implants from damage from biting forces.