Diagnosis:  After careful oral and radiographic examination, my surgeon has advised me that my missing tooth or teeth may be replaced by a dental implant.

Recommended treatment:  To place dental implant(s) under the gum and into the jawbone. To accomplish this procedure, the gum tissue is retracted back allowing the surgeon to place the dental implant(s). I understand that when there is insufficient bone, a bone graft will be placed using either my own bone harvested from my jaw and/or certified bone mineral of bovine origin (Bio-Oss). I understand that local anaesthetic will be administered to me as part of the treatment and I have the option of sedation.

Surgical phase:  In order to treat my condition, my periodontist has recommended the use of dental implants. I understand that the procedure involves placing implants into the jawbone. This procedure has a surgical phase followed by a prosthetic phase performed by my restorative dentist.

The soft tissue will be sutured over or around the implants. There will be a healing period of 3-6 months or more. In certain circumstances, I understand that dentures may not be able to be worn during the first several weeks of the healing phase.

I understand that during surgery, if clinical conditions are unfavourable for the placement of implants, my periodontist will make a professional judgement to manage the situation. The procedure may require supplemental bone grafts or other types of grafts to build up the ridge to allow for implant placement.

Expected benefits:  The purpose of dental implant surgery is to allow me to replace my missing tooth or teeth for improved function and/or to improve my appearance. The implants provide support, anchorage and retention for a fixed or removable prosthesis. This procedure has a surgical phase followed by a prosthetic phase (implant crown/bridge/denture) which is performed by your restorative dentist.

Restorative phase:   I understand that at this point, I will be referred back to my restorative dentist/prosthodontist for the fabrication of the implant crown(s) or prosthesis. This part of the process will involve additional costs with your restoring provider.

Primary risks and complications:  I understand that some patients do not respond successfully to dental implants, and in such cases, the implant may need to be removed. Because each patient's condition is unique, long term success may not occur.

I understand that complications may result from the implant surgery, drugs, and anaesthetics. These complications include, but are not limited to:

• Post surgical infection
  

• Restricted ability to open mouth

• Impact on speech

• Allergic reactions

• Injury to teeth

• Accidental swallowing of foreign objects

• Delayed healing

• Jaw bone fracture
  

• Pain, swelling and post-operative discoloration of the face, neck and mouth

• Mal-union, delayed union, or non-union of the bone graft material to normal bone

• Lack of adequate bone growth into the bone graft replacement material

• Limitation of jaw function and stiffness of jaw and facial muscles

• Referred pain to the ear, neck or head.

• Post-operative, unfavorable reactions to drugs, such as nausea, vomiting and allergies

• Unfavourable conditions for the placement of the implant(s) which may require a bone graft, or a soft tissue graft. This may delay the placement of the implant and the healing process.

• Damage to sinuses requiring additional treatment or surgical repair at a later date.

• Transient or permanent numbness of the lip, tongue, teeth, chin or gum

• Bleeding which might require more advanced techniques to control

• Failure of implant(s) integrating resulting in implant removal

I understand that if I smoke I have an increased risk of the above complications. The exact duration of any complication(s) can not be determined, and they may be irreversible.

Alternatives to suggested treatment:  I understand that alternatives to dental implant(s) surgery may include: 1) no treatment, 2) dental bridgework (if there are good adjacent teeth for supporting a fixed bridge), 3) removable dentures.

No warranty or guarantee:  It is understood that although good results are expected, they cannot be and are not implied, guaranteed, or warrantable. There is also no guarantee against unsatisfactory or failed results.  In the unforeseen circumstance an implant does fail, I understand that an implant may be replaced. The components will be replaced free of charge, however there will be a fee to cover the costs of the surgery and materials. 

Publication of records:  I authorise photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry. However my identity will not be revealed to the general public without my permission.

Sedation:  Please speak to your treatment coordinator if this is something you wish to discuss further as this requires to be arranged prior to your procedure date, with a minumum of 24 hours notice.

I understand that if I take oral sedation, I will need a driver to and from my appointment and that I should not operate any heavy equipment/machinery for 24 hours following the use of oral sedation.

Payment Terms: I understand the proposed treatment plan estimation which has been presented to me as a written treatment plan outlining the required appointments, time frames, item codes and the fees associated with my treatment. 

I understand all appointments are to be paid in full on the day of the procedure, and I will be mindful of any daily bank card limits I may have, thus ensuring full payment can be made. 

I understand that if I wish to make payment via direct deposit that I will contact my treatment coordinator at least two days prior to my appointment, ensuring the funds have cleared before the commencement of my appointment. 

I am aware that a HICAPS terminal is not available on site and I will claim any benefits that I may be entitled to directly from my health fund.

Patient Consent: I have been fully informed of the nature of the implant placement surgery, the risks and benefits, the alternative treatments available and the necessity for follow up care. I have had an opportunity to ask any questions I may have in connection with the treatment and discuss my concerns with my periodontist. I hereby consent to the implant placement surgery as presented to me during consultation and in the treatment plan presented. I understand that during the procedure, conditions may become apparent which warrant additional or alternative treatment for my best interest, which I will be informed of. This may involve additional costs that may not have been outlined in the provided treatment plan.

I understand the success of surgical procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, adequate oral hygiene, and medications that I may be taking. To my knowledge I have reported to my periodontist any prior drug reactions, allergies, diseases, symptoms, habits or conditions that in any way relate to this surgical procedure.

I have agreed to follow the post-operative instructions and to report to all follow up appointments.

Please note, due to the sterile environment, no family or friends are permitted chairside at the time of the procedure.

By providing my signature, I certify that I have read and fully understand this document and that all my questions have been answered to my satisfaction.