Consent for Implant Removal | Lunar Smile Dentistry

Patient

Patient first name

Patient last name

Date of birth

Month

Day

Year

Implant site

Reason for removal (if known)

About implant removal

Removing a dental implant is a surgical procedure. It is usually done with local anaesthetic. Serious complications are not expected, and those that do happen are usually minor and treatable. Possible complications include:

swelling, bruising and discomfort around the surgical area;
cracking or bruising at the corners of the mouth from being stretched;
infection that needs more treatment;
limited jaw opening due to swelling or inflammation, or jaw joint (TMJ) discomfort, especially if you already have a jaw joint condition; and
bleeding: heavy bleeding is uncommon, but some oozing for several hours is normal.

Rebuilding the area

When an implant is removed, your dentist may recommend placing a bone graft, membrane or other graft at the same visit. This rebuilds the jaw ridge so the site can heal well and a new implant can be placed later if wanted. Grafting has additional fees.

If your dentist recommends grafting at the same visit, they will discuss it with you before going ahead.

A few questions

If your dentist recommends grafting at the same visit, do you agree to it?

YesNoDiscuss with me first

May we use your de-identified photos and x-rays for teaching?

Nothing that identifies you is ever shared. Saying no has no effect on your care.

YesNo

Please tick each statement to confirm it is true for you

I have read this form, or had it read to me, and I understand it.My dentist has explained the procedure, why it is recommended, the possible risks, and the other options available to me, including no treatment.I have had the chance to ask questions, and my questions have been answered to my satisfaction.I understand that dentistry is not an exact science and that no particular result has been promised or guaranteed to me.I have given an accurate and complete health history, including medications, allergies, past reactions, and pregnancy if applicable.I consent to removal of the dental implant named above. If something unexpected is found during treatment, I allow my dentist to do what is reasonably necessary in my best interest, and I understand this will be discussed with me whenever possible.

Sign and submit

Your signature confirms the answers and statements on this form.

Your full name

Your email

Your relationship to the patient

Signature

Signed on

There are a few things to fix