I understand that theses charges for today are for the surgical
portion of my treatment plan, and that my general dentist will have
additional charges for the restoration of the implant(s).
Patient
Signature: _____________________________ Date: ________
Witness
Signature: _________________________ Date: _________
Surgical Procedure: __________________________________________________________
Dr. Hiru Mathur has explained to me the following:
_______ 1. The nature of my condition
_______ 2. The alternative to dental implants
_______ 3. The Risk associated with each alternative.
I have been advise that all the following could occur:
*Pain and/or discomfort, possible dizziness, infection, swelling, and bruising, bone loss and
possible implant failure.
* Parenthesis-numbness or loss of feeling sensation in the lip, tongue, chin, cheek or teeth due to
nerve trauma during swelling or surgery.
* Failure of the implant due to design or placement of the permanent prosthesis on the implant
unrelated to the implant placement procedure.
* Bone loss can be expected around an implant if there is poor oral hygiene.
*Damage to adjacent teeth, roots or crowns during surgery.
* Bone grafting procedure have the added risk of paresthesia, tissue sloughing infection, nose
bleeding and failure of graft to take.
* Fracture of jaw due to infection or inadvertent fracture caused during surgery
I accept any of these possible risks listed above. ________ (Initial)
I understand that smoking, alcohol, and excess sugar consumption will affect gum healing and
may limit the success of surgery. I also consent to photography, filming, recording and x-rays of
my procedure for the advancement of dentistry. ________ (Initial)
I give the right to the doctor to change treatment during the procedure at any time. This may be
due to unforeseen complications that might present itself during the surgery. This will be in
consideration of what is the best for your final treatment goals and long-term success of the
treatment. _________ (Initial)
Additional treatment including other surgeries may be required to obtain the final results
acceptable to you and the doctor. Unforeseen complications can arise during any care rendered to
a patient. I understand and accept that this may include additional cost and surgeries that was not
known at the beginning of the treatment or covered in your consultation. ___________ (Initial)
I READ AND UNDERSTAND THE ENGLISH LANGUAGE. I FULLY COMPREHEND
THE RISKS ASSOCIATED WITH MY SURGERY AND ACCEPT THESE RISKS. I AM
READY TO PROCEED WITH SURGERY.
Please rewrite this sentence in your handwriting.
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
_________________________________
______________________________
Patient/Parent/Guardian (print)
Patient/Parent/Guardian (Signature)
Date: _______________________
Witness: ________________________
IV Sedation Consent

I permit Dr.Mathur assisted by appropriate personnel to administer intravenous
(conscious) Sedation in the manner in which she deems appropriate in her professional
judgment for the purposes of implant surgery.

Dr. Mathur has explained the purpose and use of these sedatives, the alternative to their
use, and their usual effects. I will not drive, operate heavy machinery or sign legal
documents for 24 hours.

Dr. Mathur has explained to me that there is always the risk of complications with any
anesthesia or sedation, and the doctor has answered all questions to my satisfaction.
Date: ______________
Witness: _________________________
Age: _______
Allergies: _________________________________
Weight: ________
I authorize Dr.Matur and/or team members to perform the following procedure:
__________________________
Signature
________________
Initial
And to administer the anesthesia I have chosen, which is:
Local Anesthesia
_______________
Initial
Local Anesthesia with oral premedication
________________
Initial
IV Sedation with oral anesthesia
________________
Initial
Implant Maintenance Consent Form
As part of this consent, I ______________________________________________, do herby
accept full responsibility to see my dentist on a regular basis (every 3-6 months) for routine
cleaning and maintenance of my implants. This is to prevent bone loss, which can be expected
around an implant if good oral hygiene is not practiced. I will adhere to Dr. Mathur
recommendations and instructions after the procedure. An implant guarantee will be offered at
the end of the treatment. I will present to this office for an annual exam to preserve the life of my
implant.
____________________________
Patient’s Signature
_______________________
Date
____________________________
Patient’s Printed Name
_________________________
Date
_____________________________
Witness’s Signature
_________________________
Date
Smoking as it relates to Dental Implants
IMPLANTS PATIENTS WHO SMOKE DO NOT HEAL AS WELL AS NONSMOKERS.
Newly sutured tissue heals by clotting. When a patient inhales, they form a vacuum in the mouth
and often times dislodge the newly formed clot. Nicotine then penetrates that clot and can cause
necrosis (death in some or all cells in an organ or tissue) of the tissue.
To decrease post-op complications, our patients are instructed that they must not smoke after
their implant surgery. If the patient at any time resumes smoking after surgery numerous
complications could occur. Such as, but not limited to: Dry sockets, bone loss around the
implants, infection or failure of the dental implant. Dr. Mathur is not liable for any complications
that occur in patients that choose to smoke.
I, __________________________________, understand the above statement and agree to stop
smoking after my implant surgery. I also understand that I am responsible for any complications
resulting from the affects of smoking, such as infection or loss, if I do not follow the above
instructions.
______________________________
Patient’s Signature
_________________________
Date
_____________________________
Witness Signature
__________________________
Date
________________________________________________
Does not apply
Diabetes Patients
Patients with diabetes need to understand that they have numerous problems associated with this
disorder. Most of these problems are because of the vascular complications associated with
diabetes. This may cause the patient to be more susceptible to bone loss, infection and possibly
implant failure.
You are being informed that these complications can occur and that you must do four important
things to help this situation.
1. Regular checkups and maintain a balanced, controlled, normal sugar level. This can
only be obtained with full compliance with your physician’s supervision.
2. Maintain excellent oral hygiene as discussed with our office using Prevident with
periogard three times daily.
3. Go to your dentist at least 3 times yearly for cleaning etc.
4. Return to Dr.Mathur annually for a periodic exams.
Following these instructions does not guarantee success of your implants, but certainly
increases your chances of success. Dr. Mathur is not liable for these complications if they do
occur due to non-control or non-compliance with your diabetes.
I, ________________________________, do understand the above statements and agree to
follow these instructions.
____________________________________
Patients Signature
___________________________
Date
____________________________________
Witness Signature
____________________________
Date
_____________________________________________________________
THIS DOES NOT APPLY