Download Implant Consent Form - Maryland Oral Surgery Associates

MARYLAND ORAL SURGERY ASSOCIATES
ORAL & MAXILLOFACIAL SURGEONS
GLENN A. NATHAN, DDS
MITCHELL A. STARK, DDS*
BRADLEY S. FREY, DDS*
BRIAN T. ROBINSON, DDS, MD*
ZIAD E. BATROUNI, DDS*
LISA S. COHEN, DDS*
MARK A. PITTS, DDS*
FELLOWS* AND MEMBERS OF
THE AMERICAN ASSOCIATION OF ORAL &
MAXILLOFACIAL SURGEONS
STEVEN R. KISHTER, MD, DDS*
ALLEN A. ROBINSON, DDS*
MARY CARTER ROBINSON, DDS*
AKBAR A. DAWOOD, DMD*
RANIA A. HABIB, DDS, MD
MALINI B. IYER, DMD, MD*
www.mosa4os.com
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ENDOSTEAL IMPLANT SURGERY CONSENT FORM
You have the right to be given pertinent information about your proposed implant so that you have sufficient information
to make the decision as to whether or not to proceed with surgery. What you are being asked to sign is a confirmation that
we discussed the nature of the proposed treatment, the risks associated with it and the feasible alternative treatments.
IF YOU HAVE ANY QUESTIONS, PLEASE ASK YOUR DOCTOR.
Patient name: ___________________________________________________ Date: __________________
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BETHESDA
10401 Old Georgetown Rd
Suite #206
Bethesda, MD 20814
Phone 301-984-9111
Fax 301-984-0374
[email protected]
I hear by authorize Dr. ________________________________, and other agents, assistants, or employees
selected by him or her to treat the condition described as:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The procedure necessary to treat the condition has been explained to me and I understand the nature of the
procedure to be:
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________
I understand incision will be made inside my mouth for purpose of placing one or more endosteal root form
structures (implant) in my jaw to serve as anchors for missing tooth or teeth or to stabilize a crown (cap), bridge,
or denture. I acknowledge that the doctor has explained the procedure, including the number and location of the
incision and type of implant to be used. I understand that crown, bridge, or denture that will be attached to this
implant will be made and attached by Dr. _____________________________________ and a separate charge
will be made for work.
I understand that the implant must remain covered by gum tissue for at least three-six months before it can be
used and that a second procedure is required to uncover the top of the implant. No guarantee can be or has been
given that the implant(s) will last for a specific time period. I also understand that there will be no refund of fees
in the event of failure. It has also been explained to me that once the implant is inserted, the entire treatment plan
must be followed and completed on schedule. If this schedule is not carried out, the implant may fail.
I have been informed of possible alternative methods of treatment (if any), including:
______________________________________________________________________________
_____________________________________________________________________________
I understand the other forms of treatment or no treatment at all are choices that I have and the risk of those
choices have been presented to me.
My doctor has explained to me that there are certain inherent and potential risks and side effects in any surgery
procedure and in this specific instance such risks include, but are not limited to, the following:
a. Postoperative discomfort and swelling that may require several days of at home recuperation.
b. Prolonged or heavy bleeding that may require additional treatment.
c. Injury or damage to adjacent teeth or roots of adjacent teeth.
d. Postoperative infection that may require additional treatment.
e. Stretching of the corners of the mouth that may cause cracking and bruising, and may heal slowly.
ROCKVILLE
14955 Shady Grove Rd
Suite #330
Rockville, MD 20850
Phone 301-340-0101
Fax 301-340-1689
[email protected]
FREDERICK
6550 Mercantile Dr. E
Suite #101
Frederick MD, 21703
Phone 301-698-5208
Fax 301-698-1848
[email protected]
SILVER SPRING
1300 Spring St
Suite #350
Silver Spring, MD 20910
Phone 301-593-8077
Fax 301-593-9196
[email protected]
COLLEGE PARK
6201 Greenbelt Rd
Suite # M-1
College Park, MD 20740
Phone 301-345-7007
Fax: 301-345-5288
[email protected]
LAUREL
14333 Laurel Bowie Rd
Suite #205
Laurel, MD 20708
Phone 301-953-1888
Fax 301-953-1891
[email protected]
CROFTON
2401 Brandermill Blvd
Suite #320
Gambrills, MD 21054
Phone 410-721-0700
Fax 410-721-5459
[email protected]
ANNAPOLIS
128 Lubrano Dr.
Annapolis, MD 21401
Suite #300
Phone 410-897-0111
Fax 410-897-0110
[email protected]
MOSA
MANAGEMENT
14955 Shady Grove Rd
Suite #350
Rockville, MD 20850
Phone 301-340-6884
Fax 301-340-3836
f.
Restricted mouth opening for several days; sometimes related to swelling and muscle soreness and
sometimes related to stress on the jaw joints (TMJ).
g. Injury to the nerve branches in the lower jaw resulting in numbness or tingling of the chin, lips, cheek,
gums or tongue on the operated side. This may persist for several weeks, months, or in rare instances,
permanently. In some cases the implant may need to be removed.
h. Opening into the sinus (a normal chamber above the upper back teeth) require additional treatment.
i. If the sinus is intentionally entered (sinus lift procedure with grafting) there will usually be several
weeks of sinusitis symptoms requiring certain medications and additional recovery time.
j. Fracture of the jaw.
k. Non-integration of the implant (failure of the implant to heal properly)
l. Other: _________________________________________________________________________
7. It has been explained to me that during the course of the procedure unforeseen conditions may be revealed which
will necessitate extension of the original procedure or a different procedure from those set forth in paragraph 2
above. I authorize my doctor and his or her staff to perform such procedure as necessary and desirable in the
exercise of professional judgment.
8. I consent to the administration of ___________________________________________________________
anesthesia in connection with the procedure referred to above. If intravenous anesthesia is used, there may be
soreness at the injection site or along the vein, as well as some bruising around the injection site. In rare cases,
the vein irritation may cause restricted mobility of the arm or hand and may require additional treatment.
9. I have been made aware that certain medications, drugs, anesthetics and prescriptions which may be given can
cause drowsiness, in coordination, and lack of awareness which also may be increased by the use of alcohol or
other drugs. I have been advised not to operate any vehicle or hazardous machinery and not to return to work
while taking such medications, or until fully recovered from the effects of same. I understand recovery may take
up to 24 hours or more after I have taken the last dose of 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.
10. IF INTRAVENOUS ANESTHSIA (SEDATION OR GENERAL) IS USED: I understand that I am not to have
anything (or have not had anything) by mouth for at least 6 hours before my surgery. TO DO OTHERWISE
MAY BE LIFETHREATENING!
11. It has been explained to me, and I understand, that a perfect result is not, and cannot be guaranteed or warranted.
12. I certify that I speak, read, and write English and have read and fully understand this consent for surgery; and all
the blanks were filled in prior to my initialing and signing this form.
PLEASE ASK YOUR DOCTOR IF YOU HAVE ANY QUESTIONS CONCERNING THIS CONSENT
FORM.
____________________________________________________________________________________________
Patient’s or legal guardian’s signature
Date
_____________________________________________________________________________________________
Witness signature
Date
______________________________________________________________________________________________
Doctor’s signature
Date