STEINWAY FAMILY DENTAL CENTER 32-50 STEINWAY ST ASTORIA, NY 11103 IMPLANT CONSENT FORM Dear Patient: You have the right to be informed about your diagnosis and planned surgery. This consent form will help you make a decision whether to undergo the procedure or procedures after knowing the potential risks and hazards. This disclosure is not meant frighten or alarm you; it is simply an effort to make you better informed. Please read the following information. After you read and understand the following, complete and sign the attached consent portion of this document. Alternative treatments will be discussed with you. The advantages and disadvantages of such treatments will also be discussed. Possible Complications of Surgical Procedures Possible complications include soreness, swelling, bruising, and restricted mouth opening during healing, muscle soreness related to stress on the jaw joint (TMJ) especially when, TMJ problems already exist, bleeding (usually controllable), drug reactions, allergies and infections may occur. I have been made aware that certain medications, drugs, anesthetics and prescriptions which I may be given can cause drowsiness, incoordination and lack of awareness which also may be increased by the use of alcohol or drugs. Additionally, I may develop an allergic reaction to some of these medications. I have been advised not to operate any vehicle or hazardous machinery, and not to work while taking such medication. If I am to be given sedative medication during my surgery, I agree not to drive myself home and will have a responsible adult drive me home and accompany me until I am fully recovered from the effects of the sedation. I understand that no guarantee or assurance has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. Due to individual patient differences there are exists a risk of failure, relapse, selective re-treatment, or worsening of my present condition despite the care provided. For Female Patients It has been explained to me and I understand that antibiotics and other medications may interfere with the effectiveness or oral contraceptives. Therefore, I understand that I will need to use some additional form of birth control, for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Additionally, I understand that fungal infections may be a common result of antibiotic therapy.