DENTAL CARE CENTRE ,HYDERABAD
INFORMED CONSENT FORM FOR ENDOSTEAL IMPLANT SURGERY
Name: ..................................... (S/o, D/o, W/o)...............................Gender..........
.........Age...................................
1. I do hereby give my voluntary consent to Dental Care Centre and its dental practitioner(s)
(Practitioner) to perform on me treatment, surgical operation, and diagnostic/therapeutic
procedure including treatment for any unforeseen emergencies. I am aware that the clinic is under
CCTV surveillance.
2. I have been explained the procedure in detail which is as
follows:__________________________________
3. I understand that one or more Implants will be placed in my jaw to serve as anchors for missing
teeth for stabilizing crown, bridge or denture.
4. I fully understand that, I will have to pay separately for Prosthesis (Crown, bridge or denture,
placed over Implant); and with my consent for Bone grafting or any additional implant used
during surgery.
5. I understand that it takes 3-6 months or more for bony union before the implant can be loaded. In
some patients, there may be enhanced healing period needed due to glucose imbalance,
osteoporosis, deficiencies, certain medical conditions, pre-existing diseases or habits like
smoking etc.
6. I am informed that a 2nd procedure is required to start making crown over implant. I acknowledge
that the doctor has explained the procedure, including the number, location and type of implants
and no Guarantee can be given that implant(s) will last for a specific time period. There may be
difference in number of Implants (less or more) implanted during surgery, depending upon bone
condition, for which I give my consent.
7. Side effects related to surgery have been explained to me which are, and not limited to the
following:
1. a) Discomfort and swelling, post-operative infection or post-operative bleeding may
rarely happen.
2. b) Restricted mouth opening or pain in joint for a short duration.
3. c) Numbness or tingling of affected area rarely for short duration.
4. d) Lack of proper bony union of implant with bone sometimes occur resulting in longer
healing period.
5. e) However, in case of loosening of implant; another procedure for placement after a
healing time and bone grafting may be required.
6. f) Additional procedure for my medical condition for Implant stability may be necessary.
.
8. I have informed the Dental Surgeon my complete medical history/ailments/operations undergone
and name/dosage of medicines being taken by me and the name of medical specialist under
whose care I am.
9. I have been explained that any worsening or deterioration of my medical condition, or drastic
change in blood parameters like Glucose, Calcium, Vitamin D, Hormones, Vitamins, Salt & other
minerals etc. can directly affect the success of implants and it’ll be in my interest to keep these
under normal limits.
10. I hereby grant my unconditional consent for administration of Local/General
Anaesthesia in connection with the procedure referred to above. I am advised not to take
alcohol or tranquilizers before the treatment as they enhance drowsiness. I have been advised not
to drive/operate any vehicle on my own until the anaesthetic affect wears off and preferably have
an attendant along.
11. I understand and acknowledge that this consent form and the treatment provided to me, shall be
governed by the Indian laws and will be under the jurisdiction of Hyderabad Courts.
Name & Signature …………………………….. Date…………………Relationship with
Patient…………………