IMPLANT & BONE GRAFT CONSENT FORM


I hereby authorize Dr. Gregory Broyde and his assistants (to assist) to insert dental implant(s) in my jaw and/or bone grafts as needed.

The placement of the titanium implant(s) in the jaw will serve as a tooth replacement or anchor to stabilize a bridge or denture. The implant may be covered underneath your gum for a few months and may not get the final crown placed until later.

The alternatives to implant treatment include; No treatment at all, bridge, partial denture or complete denture depending on the nature of your clinical situation.

I have been informed there are risks and complication that can arise that include but are not limited to:

  • Infection
  • Implant Failure
  • Additional procedures needed
  • Injury to adjacent teeth
  • Gums receding, exposing implant
  • Bone/Jaw fractures
  • Possible nerve damage (Temporary, long term or in rare cases, permanent)
  • Longer than expected time until final crown/bridge/denture is delivered
  • Tissue discoloration/bruising
  • Sinus penetration (Upper Implants)
  • Bleeding at implant site
  • Scarring on gums

I understand that the final bridge/crown/denture is another procedure that will be placed is another procedure that will be placed later and the fees are separate from the implant fee. I understand there is no way to accurately predict the healing of any patient including the final height of the gums, and that there has been no guarantee given. I understand that meticulous oral hygiene must be maintained, and that smoking, alcohol, and improper diet practices must be avoided. If I fail to do so, bone healing/implant integration may be slowed or fail.

I understand that periodic cleanings and exams are very important to the success of the implant. Any bite changes or even slightly looseness in the crown or implant must be reported immediately as it will NOT return to normal and the implant may fail.

I understand that many insurances choose not to pay towards implant related treatment (Includes but is not limited to services such as Bone Grafts, Sinus Lifts & Ridge Splits). I acknowledge that I have had the opportunity to discuss payment options with a treatment coordinator prior to commencing this treatment and have made the necessary payment arrangements.


CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH; IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.