Name of patients with oral implant prosthesis in the treatment of informed consent: gender, age, medical record number: introduce disease and treatment recommendations:
The doctor has told me that I have ___________ and need oral implant repair treatment under ____________ anesthesia.
Treatment introduction and expectations:
Potential risks and countermeasures and the doctor told me the following oral implant prosthesis treatment may be some risk, the risk of some unusual there may not be on this list, specific treatment according to the different patient’s situation is different, the doctor told me to discuss with my doctor about my treatment, the specific content of the if I have special problems to discuss with my doctor.
1. I understand that there are risks associated with any anesthesia.
2. I understand that any medication used may have side effects, ranging from mild nausea and rashes to severe anaphylactic shock, even life-threatening.
3. I understand the possible risks of this treatment and the countermeasures of the doctor: 1) intraoperative injury of nerves, blood vessels and adjacent organs, such as ______________;
2) Bone lateral wall perforation;
3) Adjustment and injury of adjacent teeth and matched teeth;
4) Intraoperative and postoperative bleeding;
5) Maxillary sinus perforation;
6) Local swelling and pain;
7) Various infections (bacteria, fungi, viruses, etc.);
8) Local subcutaneous congestion and instant skin discoloration;
9) Local real-time or permanent numbness;
10) Jaw fracture;
11) Induce systemic complications;
12) Poor healing of the implant;
13) Implant shedding;
14) The color of the prosthesis is close to but not exactly the same as the natural tooth. It is more difficult to match the color of the tooth with complex color, and there is color difference between the prosthesis and the natural tooth.
15) The surgical plan may be changed or the operation may be terminated during the operation;
16) Sometimes the function and beauty cannot be successfully balanced or the beauty cannot reach the expectation, such as;
17) Regular review, periodontal maintenance and treatment are required after implant surgery;
4. I understand that if I do not follow the doctor’s advice after treatment, the treatment effect may be affected.
Specific risks or major high risk factors: I understand that according to my personal condition, I may have the following special complications or risks: In the event of the above risks and accidents, the doctor will take active measures.
Informed choice My doctor has informed me of the procedure to be performed, the procedure and the complications and risks that may occur after the procedure, other possible treatments, and answered my questions about the procedure.
I agree that in the operation, the doctor can adjust the scheduled operation mode according to my condition.
I understand that my procedure requires multiple doctors.
?
I was not promised 100% success.
I authorize the physician to dispose of surgically removed diseased organs, tissues or specimens, including pathological examination, cytology, and disposal of medical waste.
Signature of patient: Signature of doctor: Signature of client/legal guardian: Relationship with patient: Year Month Date:
