Consent For Implant Surgery – Dr. Kolinski

  1. I have been informed of the purpose and the nature of the implant procedure. I understand in basic terms what is surgically necessary to accomplish implant placement.
  2. Alternative recommendations for restorative dentistry, including removable and/or fixed type replacement dentistry have been explained to me by Dr. Kolinski. The option of no replacement at this time has also been discussed. I have tried and/or considered these alternative methods of care, and I prefer implant placement to replace my missing and/or failing teeth. I understand the benefits of implant supported dentistry, including no need for partials, no need to cut down good teeth for a fixed bridge, and the ability to chew food more effectively.
  3. I have been informed of the possible risks involved with implant placement, including excessive bleeding and infection. I understand these risks can be minimized by following the preoperative and postoperative instructions provided. I agree to schedule postoperative observation appointments per the treatment plan, and to take the recommended medications as prescribed by Dr. Kolinski.
  4. I understand the possibility of permanent numbness as a result of implant placement does exist, but that the incidence of numbness is extremely low. I have been advised that Dr. Kolinski has performed a thorough examination and has taken all necessary precautions to prevent permanent numbness by reviewing x-rays and study models as necessary.
  5. I understand that in some instances implants can fail and must be removed. No guarantees or assurances as to the outcome of treatment or surgery can be made. The success rate of implants is approximately 95 percent. I have been advised that if infection or failure occurs, the treatment plan may take longer and require more surgery than if there are no adverse reactions. I understand that there is a 1-3 percent possibility for implant failure following final restorative care.
  6. I have been advised that smoking and excessive alcohol use can adversely affect the body’s ability to heal and will reduce the success rate of implant placement. I understand that when a failure does occur for a patient with these habits the resulting bone loss can be exacerbated. Replacement may not be possible or recommended after failure of an implant in patients with these habits.
  7. To my knowledge, I have given an accurate report of my physical and mental health on the Health Information Sheet.
  8. I have been informed in writing of the fees for implant placement and bone reconstruction that may be necessary. I also understand that additional hard and/or soft tissue may be necessary, and that these fees are in addition to fees for implant placement. I understand additional fees will be charged by my general dentist for completion of the restorative aspect of my care.
  9. I request and authorize medical/dental services for me, including implant placement and associated surgery as outlined by Dr. Kolinski. I fully understand that during and following the contemplated procedure, surgery or treatment, conditions may become apparent which warrant, in the judgment of Dr. Kolinski, additional or alternative treatment pertinent to the success of the comprehensive treatment plan. I also approve any modification in design and material, including the use of organic or synthetic bone graft material procured from an established tissue bank, or care, if it is felt this is for my best interest.
  10. I have read and understand the above.

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