IMPLANTSCONSENTFORMsteinwayfamilydentalcenter

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.

IMPLANTS
I authorize and direct my doctor (s), with associates or assistants of his (their) choice, to provide
such services as he (they) may deem reasonable and necessary, including, but not limited to, the
administration of anesthetic agents; the performance of necessary laboratory, radiological (xray),
and other diagnostic procedures; the administration of medications orally, by injection, by
infusion, or by other dentally accepted route of administration; and the removal of bone,
cartilage, tissue, and fluids for diagnostic and therapeutic purposes and the retention of disposal
of same in accordance with usual practices. If an unforeseen condition arises in addition to or
different from that now contemplated, I further authorize and direct my doctors (s) to do
whatever he deems necessary and advisable under the circumstances, including the decision not
to precede with the implant procedure.
Alternatives to implant surgery have been explained to me, including their risks. I have tried or
considered these methods and their risks, but I desire an implant to help secure the replaced
missing teeth. I consent to the placement of an implant under the gum and in the bone and I
understand the implant surgery procedure.
I am aware that the practice of dentistry and dental surgery is not an exact science and I
acknowledge that no guarantees or assurances have been made to me concerning the success of
my implant surgery and the associated treatment and procedures. I am aware that there is a risk
that the implant surgery may fail, which might require further corrective surgery or the removal
of the implant with possible complications associated with the removal.
The implant surgical procedure has been explained to me and I understand the nature of this
surgery and anesthetic procedure to be as follows: I will receive local anesthesia (and/or possibly
an I.V. injection of a sedative). After I feel numb, the gum tissue will be removed from the bone
and a very specific metal implant will be inserted into the bone. The gum tissue will be closed
over the implant and sutured. I will be given post-op instructions and certain medications. As
with any surgical procedure, there are possible complications of which I have been informed.
These include, but are not limited to: limited oral function; post-operative pain; bleeding;
infection or abscess which may require treatment and drainage; temporary bruising of the face;
allergic reaction to medications; a change in sensation or numbness to the lip, chin, gum and/or
tongue which may be of temporary or permanent nature; an opening between the mouth and
sinus which may result in an infection and/or persistent opening requiring other surgical
procedures to resolve; injury to the teeth; tempromandibular joint (jaw) problems; and poor
healing which may result in loss of implant. I have been advised that there is a risk that the
implant or crown attached to the implant may break which could require additional procedures
including surgical removal of the implant.
I further understand if nothing is done to correct my dental condition, any of the following may
occur: limited oral function; gum or bone disease; loss of bone; inflammation; infection;

sensitivity; looseness and/or loss of teeth; shifting of teeth with bite changes; and
tempromandibular joint (jaw joint) problems; and an inability to place implants at a later date
due to changes in oral and medical conditions.
I have been advised that excessive use of alcohol, tobacco, drugs, or sugar may effect gum
healing and may limit the success of the implant. Because there is no way to accurately predict
gum and bone healing capabilities of each patient, I agree to follow my doctor’s home care
instructions and to report to my doctor for regular examinations as instructed.
I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more until
fully recovered from the effects of the anesthesia or drugs given for my care as selected by my
doctor.
To my knowledge I have given an accurate report of my physical and mental health history. I
have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics,
pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other
conditions relating to my health or any problems experienced with any prior medical, dental or
health care and treatment. If I am currently in treatment for any health problems, I certify that I
have discussed the proposed implant procedure with my healthcare provider and have received
his/her consent to undergo this implant procedure.
I fully understand that during the following the contemplated procedure, surgery or treatment,
conditions may become apparent which warrant, in the judgment of my doctor(s), additional or
alternative treatment pertinent to the success of the comprehensive treatment and therefore
authorize such treatment modifications or alternatives as may become necessary in the judgment
of my doctor(s).
I certify that I have read, have had explained to me, and fully understand the foregoing consent
to implant surgery, drug and anesthetic procedure(s), and that it is my intention to have the
foregoing carried out as stated. I have been advised that this is a relatively new procedure and
that information concerning that longevity of the particular implant to be used is not available.
However, I have discussed this as well as the nature of the implant product to be used and I
consent to the procedure knowing the risks and limitations.

PATIENT NAME:
_______________________________________________________________________
I hereby authorize my doctor(s) and staff to perform the following procedures:
_____________________________________________________________________________________
_____________________________________________________________________________________
I understand the doctor may discover other conditions that may require additional procedures. I
authorize him to perform such other procedures, as he deems necessary in his professional
judgment in order to complete my treatment.
I have read and discussed the procedure with Dr. Terranova and believe I have been given
sufficient information to give my consent to the planned surgery.
Patient’s (or legal guardians’ signature)
Date
Witness’ Signature
Date
Doctor’s Signature
Date
Albert Malakov, DDS
Aleksandr Dayanayev, DDS
Victor Terranova, DMD, MS, Ph. D