Dentistry On 66

Implant Consent Form


By signing this form, I attest that I understand, agree and consent to the following, which have been discussed
with me in detail both verbally and in writing.

  • That alternatives to dental implant placement and the implications or results of not restoring the space have been discussed.
  • The placement of dental implant(s) in the discussed tooth positions in one or both jaws as discussed with the dentist.
  • The possibility of, at the time of surgery, not placing the implant due to inadequate bone requiring further healing, grafting or referral to a specialist to achieve the desired result.
  • The possibility of requiring a minimum of 3 appointments over 3-6 months of healing, dependent upon time required for satisfactory healing.
  • The possibility of requiring a subsequent appointment to uncover the implant with minor surgery before an impression can be taken.
  • I am aware of a normal success rate of 95% in the lower jaw and 88% in the upper jaw and that no guarantees are made regarding success of treatment, however, most outcomes are quite satisfactory.
  • Smoking lowers the above success rate and may result in failure of the Implant to integrate.
  • The possibility of one or more of the implants not fusing to my jaw as intended or that a localized infection may develop requiring removal via simple surgery.
  • The possibility of pain, bleeding, bruising, swelling, infection, and reaction to any administered drugs.
  • The possibility of permanent numbness of the lower lip, teeth, tongue and chin on the treated side of the lower jaw.
  • The possibility of creation of a hole between the sinus and the mouth possibly require subsequent surgery or referral to a specialist for treatment.

I have read and understood the above mentioned information clearly. I voluntarily choose to undergo treatment with Dr Ziad Al Azawi/Dr Shieh and give consent to conducting all necessary procedures that has been explained to me for the
replacement of my missing teeth.

do66 implant consent
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