Patient Name*

First Last

I hereby request and authorize Dr. Okuyama to provide me with oral implants.
The procedure has been fully explained to me, and I understand that success with implants depends on the cooperation of the patient, and on the individual body response that cannot be accurately determined prior to the placement of implants.
I have been made aware of the following possible complications: improper occlusion, prosthetic and/or material failure, loss of permanent teeth, loss of prosthesis and/or the implant should dental disease develop due to improper home care, loss of the implant and/or prosthesis should systemic disease develop, and wear or breakage of the implant component and or the prosthesis. Other complications may occur that cannot be predicted at this time. Should any of the complications occur, I understand that there may be a need to surgically remove the implant and the use of alternative forms of treatment.

Specific Complications Related to My Care May Include:*

I have been made aware that smoking will jeopardize the integration of the implant and the long term health of the entire restoration complex. The excessive use of alcohol and sugar will have an adverse effect on my body’s response, and may therefore affect the success of the implant, as will my cooperation in performing prescribed home care.
I understand that should the implant fail for any of the above reasons, I may require corrective surgery, and/or the modification of the restoration.
Alternative treatment plans have been fully explained to me along with possible outcomes and risks.
I understand that I am to return to the dental office at regular intervals for the purpose of examining the status of the implant and my oral health, and that a reasonable fee will be charged for such visits.
I hereby authorize the taking of photographs of my mouth and implants during the course of treatment, and that they may be used for educational purposes, with the understanding that all reasonable efforts will be taken to hide my identity.
I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the use of the implants. I also understand that temporary restorations are not permanent restorations and that “permanent” restorations may need repair or re-make within 15 years.
I have been given this form to be taken home on (date) ________________________________________________for review.
I have had the opportunity to discuss all of the above on (date)__________________________________________with Dr. __________________________________________________________ and have had all my questions answered.
I certify that I fully understand all matters as described in this AUTHORIZATION AND CONSENT FOR IMPLANTS.

I have had the opportunity to discuss all of the above with Dr. Okuyama and have had all my questions answered.

I certify that I fully understand all matters as described in this AUTHORIZATION AND CONSENT FOR IMPLANTS.

Patient Signature*

Date*

Time*

:

Witness's Signature*

Implants

AUTHORIZATION AND CONSENT FOR IMPLANTS