9 Holly Hill Drive
Petersburg, Virginia 23805-2559

(804) 733-9490

FAX (804) 733-3564

10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460


  1. I have been informed, and I understand the purpose and the nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.
  2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire an implant or implants to help secure the replaced missing teeth.
  3. I have been further informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are inflammation of a vein, injury to teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medications used, etc.
  4. I understand that if nothing is done, any of the following could occur; bone disease, loss of bone gum, gum tissue inflammation, infection, sensitivity, looseness of teeth, followed by necessity of extraction. Also possible are temporo-mandibular joint (jaw) problems, headaches, referred pains to the back of neck and facial muscles, and tired muscles when chewing.
  5. My doctor has explained that there is no method to accurately predict the gum and the bone healing capabilities in each patient following the placement of an implant
  6. It has been explained that, in some instances, implants fail, and must be removed. I have been informed and understand that the practice of dentistry is not an exact science; no guarantee or assurance as to the outcome of results or treatment or surgery can be made.
  7. I understand that excessive smoking, alcohol, or sugar may affect gum healing and may limit the success of the implant. I agree to follow my doctor’s home care instructions. I agree to report to my doctor for regular examinations as instructed.
  8. I agree to the type of anesthesia, depending on the choice of the doctor. 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.
  9. 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 related to my health.
  10. I consent to photography, filming, recording, and x-rays of the procedure to be performed for the advancement of implant dentistry, provided by identity is not revealed.
  11. I request and authorize medical/dental services for me, including implants and other surgery. I fully understand that during and following the contemplated procedure, surgery, or treatment, conditions may become apparent which warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success or comprehensive treatment. I also approve any modification in design, materials, or care, if it is felt this is for my best interest.
  12. In my case, I further understand that if there is not enough natural jaw-bone to place the proposed implant, a procedure called a "sinus lift" is planned. This procedure involves opening the sinus cavity in my upper jaw and placing a bone graft, or raising the floor of the sinus as a "mini lift". I have been informed that the bone may come from a bone substitute, my jaw bone, or specially prepared donated bone. I have been informed there is a possibility of sinus perforation or infection which may require future surgery or management.

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