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1.
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I have been informed of the nature of my dental
condition and the nature of the proposed implant
surgical procedure. My dentist has explained to me
the available alternative methods of treatment and
their advantages and disadvantages.
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2.
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I understand that there are potential risks and
complications associated with any surgical
procedure. These include, but are not limited to:
post-operative pain and swelling, bleeding,
bruising, infection, temporary or permanent numbness
of the lip, chin, tongue or cheek, and sinus
complications.
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3.
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I understand that smoking and/or alcohol consumption
can significantly decrease the success rate of the
implant procedure and may lead to implant failure.
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4.
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I consent to the administration of such anesthetics
as may be considered necessary or advisable by the
dentist for this procedure.
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5.
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I have provided an accurate and complete medical and
dental history, including all medications I am
currently taking, both prescription and
non-prescription.
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6.
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I understand that dental implants are not guaranteed
and that no promise has been made to me as to the
results of the surgery or the longevity of the
implant.
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7.
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I understand that once the implant is placed, it is
my responsibility to maintain excellent oral hygiene
and to attend regular follow-up appointments as
recommended by my dentist.
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8.
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I consent to the taking of photographs or other
audiovisual records of my dental treatment for
clinical and educational purposes.
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9.
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I authorize Dr. David Gouett and his associates to
perform the implant surgical procedure as described
to me. I have had the opportunity to ask questions
and all of my questions have been answered to my
satisfaction.
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