IV Conscious Sedation Implants Step 1 of 8 12% IMPLANT SURGERY INFORMATION AND CONSENT FORM I have been informed of and I understand the purpose and nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone. My doctor has carefully examined my mouth and explained alternatives to this treatment have been explained to me. I have either tried or have considered these options and have concluded that an implant is my treatment of choice to secure the tooth or denture to be replaced. I have further been informed of the possible risks and complications involved with surgery, drugs (allergic or adverse reactions) and anesthesia. Such complications include pain, swelling, infection, bruising. Numbness of the lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Other possible risks are injury to other teeth, bone fractures, sinus perforation, delayed healing, rejection of the implant. It has been explained to me that in some instances implants fail and must be removed. The success rate of dental implant surgery is very high but dentistry is not an exact science and no guarantee or assurance as to the outcome of the result of treatment can be made. I understand that if nothing is done any of the following could occur: loss of bone and/or gum tissue, inflammation of the gums, infection, loose teeth, loss of teeth, and the occurrence or reoccurrence of Temporomandibular (jaw) joint symptoms I understand that excessive smoking, alcohol, or sugar may affect healing and may limit the success of the implant. I agree to follow my doctors home care instructions. I agree to report to my doctor for regular examinations as instructed. To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, reported any bleeding disorders or any other condition related to my health I consent to the photographing filming videotaping of the procedure to be performed provided my identity is not revealed. I request and authorize the dental services for me, including implants and other surgical procedures as deemed necessary to accomplish the placement of the implants. I fully understand that during and following the procedure conditions may become apparent that warrant additional or alternative treatments pertinent o the success of the comprehensive treatment. I also approve any modification in the design or materials if it is felt to be in my best interest. The fees for this treatment plan and the payment plan have been explained to me and I have approved them.INFORMATION AND CONSENT FORM I acknowledge that I have read this document APPENDIX TO SURGICAL INFORMED CONSENT Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED. IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST. If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email email@example.com APPENDIX TO SURGICAL INFORMED CONSENT I acknowledge that I have read this document Ontario’s Narcotics Strategy List Of Approved Forms Of Identification Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications. Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else. The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed. Below is a list of forms of identification that a person can present to a prescriber or dispenser: Ontario Health Card or other health card issued by a Province or Territory in Canada Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction) Ontario Photo Card Birth Certificate from a Canadian province or territory Government-issued Employee Identification Card Ontario Outdoors Card BYID (age of majority card) Certificate of Indian Status Valid Passport – Canadian or other country Certificate of Canadian Citizenship Canadian Immigration Identification Card Permanent Resident Card Canadian Immigration Identification Card Old Age Security Identification Card Canadian Armed Forces Identification Card Royal Canadian Mounted Police/Provincial/Municipal Police Identification Firearms Possession and Acquisition Licence Ontario’s Narcotics Strategy I acknowledge that I have read this document POST OP FOR DENTAL IMPLANTS Smoking: Do not smoke. Patients who smoke will experience delayed healing and greater discomfort and are at higher risk for infection. In addition smoking will compromise your result. Medication: It is important to follow the instructions written on your prescription. If you experience any unfavourable reactions such as nausea, vomiting, diarrhea, rash, etc. call the doctor. Rest: Do not plan on any activities for the remainder of the day. Avoid any strenuous activity for 1 week following surgery. Pain: Some discomfort is expected once the anesthetic wears off. If you were prescribed post-operative pain medication, begin taking it before the anesthetic wears off to minimize discomfort. Ibuprofen is an effective pain medication and also reduces swelling. It can be taken for the first 3-4 days on a continuous basis (4 times per day) with a maximum dose of 3 grams per day. You may take Ibuprofen in addition to and at the same time as a prescribed narcotic such as Tylenol #2 or #3. Swelling: Some swelling may occur the day after surgery and will generally persist for 24-36 hours, then diminish.Swelling can be minimized by placing an ice pack on the outside of the face over the surgical site alternating on and off in 10 minute intervals. You should do this forthe 24 hours following your surgery. Bleeding: There should be no outright bleeding after surgery, though a slight pinkish colour to your saliva is common. If bleeding occurs, place a moistened non herbal tea bag over the area and apply gentle pressure. Continue this for 20 minutes. If bleeding persists call the doctor. Rinsing: Following your surgery you should rinse with warm salt water for the next 24 hours. Do not brush or floss or water pik in the area involved in the surgery. If you have been prescribed mouthwash use it twice daily until the stiches are removed. Make sure there is no toothpaste in your mouth when rinsing. Diet: It is important to maintain a normal healthy diet. Do not drink any hot drinks for the first 24 hours. The 4 days following surgery eat soft foods (oatmeal, cottage cheese, eggs, avocado, fruit and vegetable juices) Try to do your chewing on the opposite site of your mouth from where the surgery took place. Avoid any coarse foods such as seeds, nuts, chips, popcorn etc. . . . It may be necessary to maintain a liquid diet for a few days. Increase your fluid intake during this time. Avoid using a straw for 4 days. Dr. Brian Kumer(416) 605-0008 POST OP FOR DENTAL IMPLANTS I acknowledge that I have read this document PRE-SEDATION INSTRUCTIONS IF YOU DO NOT FOLLOW THE IV SEDATION INSTRUCTIONS, YOUR APPOINTMENT WILL BE CANCELLED A: Do not eat or drink anything (EXCEPT WATER) for at least 8 hours prior to your appointment. B: You may drink water (ONLY), at least 3 hours before the appointment. If you need to take medications prescribed by your physician, TAKE IT WITH SIPS OF WATER ONLY, AT LEAST 3 HOURS prior to your appointment. You must have a responsible ADULT (relative or friend) escort you home in a car or taxi. You may not take public transit home! Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish Do not drink grapefruit juice for at least 24 hours prior to surgery. Contact us prior to your appointment if there has been a change to your general health. IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL DR. BRIAN KUMER416 605 0008PRE-SEDATION INSTRUCTIONS I acknowledge that I have read this document POST SEDATION INSTRUCTIONS Do not drive or operate hazardous equipment for 24hrs after sedation. A responsible person should remain with the patient for 24 hours. Patients must not go up or down stairs unescorted for 24hrs. No unattended bath or shower for 24 hrs. Diet is restricted by surgical procedure not the sedation. Drink plenty of fluids, 1.5-2 litres per day in the first three to four days. Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner. Don’t use any pillows for the first night. No alcohol for 24hrs Do not sign any important or legal documents for 24hrs. Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately. Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killers are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist. DR. BRIAN KUMER416 605 0008POST SEDATION INSTRUCTIONS I acknowledge that I have read this document IVCS Consent Dr. Brian Kumer DDSConsent for I.V. Conscious Sedation This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation. The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year. I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent. I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother. Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation. I have been advised of and completely understand the risks, benefits, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer. I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees. I certify that I fully understand the terms within the above consent. IVCS Consent I acknowledge that I have read this document Pre-Anaesthesia Questionnaire Patient ID *first 3 letters of your first name and the first 3 letters of your last name.:* Date (Please add today's date)* MM slash DD slash YYYY Date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex:*MaleFemaleOther1. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?* Yes No Not Sure 2. Do you have any health problems or concerns presently?* Yes No Not Sure Please explain*3. Has there been ANY change in your general health in the past year?* Yes No Not Sure When did you last have a complete physical exam?* How often do you see your family doctor or specialist?* 4. Have you ever been in hospital for treatment?* Yes No When, where and why?* 5. Have you ever had IV Conscious Sedation?* Yes No Not Sure When, where and why?* Were there any problems with the Sedation?* 6. Have you had any problems with IV Conscious Sedation?* Yes No Not Sure Please explain*Were any tests done?* 7. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)? If yes provide Pharmacy name + number of ALL pharmacies you use.7. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)?* Yes No Name of Pharmacy & Phone Number:* 8. Do you use or take ANY NON-PRESCRIPTION remedies (including herbal remedies)?8. Do you use or take ANY NON-PRESCRIPTION remedies (including herbal remedies)?* Yes No 9. Are you allergic to any medications?* Yes No Not Sure What drugs?* What year?* What happened? (Circle) rash breathing problems/wheezing swelling:* 10. Do you have any other allergies (e.g. latex)?* Yes No Not Sure Other allergies* 11. Do you take any medications for Osteoporosis? ( Bisphosphonates etc. )* Yes No Not Sure Name of Pharmacy and Phone Number*12. Do you take 81 mg ASA, daily?* Yes No Not Sure 13. Have you taken a cortisone (steroid) type drug orally in the past year?* Yes No Not Sure When? How long were you taking it for?* 14. Do you or any of your relatives have a bleeding problem?* Yes No Not Sure 15. Do you have or have had any difficulty breathing through your nose?* Yes No Not Sure 16. Do you have any nose bleeds?* Yes No Not Sure If so, how many per week?* 17. Do you have or have had any difficulty breathing while sleeping at home?* Yes No Not Sure 18. Do you have or have you ever had any of the following? Heart murmur:* Yes No Not Sure Heart attack:* Yes No Not Sure Chest pain or angina:* Yes No Not Sure Shortness of breath lying down:* Yes No Not Sure Swollen ankles:* Yes No Not Sure Heart pacemaker/defibrillator:* Yes No Not Sure Irregular heart beat/arrhythmia:* Yes No Not Sure High blood pressure:* Yes No Not Sure Shingles:* Yes No Not Sure Congenital heart disease:* Yes No Not Sure Damaged/abnormal heart valves:* Yes No Not Sure Rheumatic fever:* Yes No Not Sure Kidney disease:* Yes No Not Sure HIV, AIDS or STD:* Yes No Not Sure Cancer / Chemotherapy:* Yes No Not Sure Sleep apnea:* Yes No Not Sure Asthma:* Yes No Not Sure Emphysema / Bronchitis:* Yes No Not Sure Cystic fibrosis / Tuberculosis:* Yes No Not Sure Epilepsy:* Yes No Not Sure Stroke:* Yes No Not Sure Fainting spells, dizziness:* Yes No Not Sure Diabetes:* Yes No Not Sure Thyroid Disease:* Yes No Not Sure Adrenal gland disorder:* Yes No Not Sure Hepatitis:* Yes No Not Sure Liver disease / Jaundice:* Yes No Not Sure Anemia (including sickle cell):* Yes No Not Sure Blood disorders/transfusions:* Yes No Not Sure Bleeding (Coagulation) disorders:* Yes No Not Sure Stomach ulcers/ Acid Reflux:* Yes No Not Sure Bone, joint, or muscle problems:* Yes No Not Sure Artificial joints - hips, knees:* Yes No Not Sure Arthritis:* Yes No Not Sure Depression / anxiety:* Yes No Not Sure Vision problems / glaucoma:* Yes No Not Sure Mentally disabled:* Yes No Not Sure Cerebral palsy:* Yes No Not Sure Autism or Down's syndrome:* Yes No Not Sure Are you pregnant?* Yes No Not Sure Are you a nursing mother?* Yes No Not Sure Any problems with menstruation?* Yes No Not Sure 19. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?* Yes No Not Sure 20. Do you have any problems opening your mouth wide or moving your neck fully?* Yes No Not Sure 21. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?* Yes No Not Sure 22. Do you smoke?* Yes No Not Sure If so how much?* 23. Do you drink more than 5 alcoholic beverages per week? Number/week* Yes No Not Sure Number/week* 24. Do you have a history of alcoholism or drug dependence?* Yes No Not Sure 25. Have you taken any recreational drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, crystal meth, codeine, oxycodone or other drugs?* Yes No Not Sure 26. Do you have ANY disease, condition or problem not listed above?* Yes No Not Sure Explain:*What's your weight (lbs)* What's your height?Feet*1234567Inches*1234567891011.5Any additional information you wish to convey to Dr. Kumer please explain below:CAPTCHAEmailThis field is for validation purposes and should be left unchanged.