Aziz Bohra, DMD, MS

13065 W. McDowell Suite A101, Avondale, Arizona 85392

623-935-0004

Implant Consent Form

Patient Name:
Email
Cell Phone

1. Authorization - I hereby authorize Dr. Bohra/Dr. Siu to administer local anesthetic and insert dental implant(s) in my jaw as needed to replace the roots of tooth/teeth numbers If necessary, bone graft (sterilized human bone) will be placed, in order to provide a sufficient platform for the dental implants.

2. Nature and Purpose of the procedure - The placement of the titanium implant(s) in the jaw will serve as an anchor to stabilize a bridge, crown, or denture. I understand that the bridge/crown/denture (the restoration) is a separate procedure that will be placed at a later date by my general dentist and the fees are separate from the implant fee due to Dr. Bohra/ Dr. Siu, after a healing period of 2-6 months. I understand the implant(s) will be concealed underneath my gum tissue for a several months and the final restoration will not be placed until later.

3. Alternatives to a dental implant - The alternative treatments include no treatment at all, bridge, partial denture or complete denture depending on your clinical situation.

4. Risks and Complications - I have been informed that there are risks and complications that can arise that include but are not limited to:

  1. Infection
  2. additional procedures needed
  3. injury to adjacent teeth
  4. gums recede exposing implant
  5. bone/jaw fractures
  6. restoration delayed
  1. implant failure
  2. tissue discoloration/bruising
  3. sinus penetration
  4. prolonged/permanent numbness
  5. scar on gums

5. I know that it is important to:

  1. Abide by the specific prescriptions and instructions given.
  2. See Dr. Bohra/ Dr. Siu for post-operative check-ups as needed.
  3. Quit smoking. Implant failure rates are several times higher in smokers.
  4. Perform excellent oral hygiene once instructed to, usually starting 1 week after the surgery is done.
  5. Have my dentist restore the implant(s) once they are healed.

6. Expected Benefits: The purpose of dental implants is to allow me to have more functional artificial teeth. The implants provide

7. No Guarantee of treatment results - I understand that there is no way to accurately predict the healing of any particular patient

8. Importance of patient compliance - I understand that meticulous oral hygiene must be maintained and that smoking, alcohol, and improper diet practices must be avoided. If I fail to do so, bone healing/implant integration may be slowed or the implant may fail.

9. Periodic checkups - I understand the periodic cleanings and exams are very important to the success of the implant. Any bite changes or even slight looseness in the crown or implant must be reported immediately, as it will not return to normal on its own and therefore the implant may fail.

Patient's Signature:

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Date:

Witness Signature:

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