Non Sedation Implants "*" indicates required fields Step 1 of 5 0% 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 CONSENTDr. 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 drkumerquestions@gmail.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 Old Age Security Identification Card Canadian Armed Forces Identification Card oyal 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 MEDICAL HISTORY The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Sex:*MaleFemaleNot SureDate (Please add today's date)* Patient ID *first 3 letters of your first name and the first 3 letters of your last name:*Date of birth:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What's your weight (lbs)*What's your height?Feet*1234567Inches*1234567891011.51. Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why?* Yes No Not Sure Explain:*2. When was your last medical checkup?*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?*When did you last have a complete physical exam?*How often do you see your family doctor or specialist?*When did you last have a complete physical exam?*How often do you see your family doctor or specialist?*Has there been any personal or family history of issues with anesthesia, IV Conscious sedation?* Yes No Not Sure 4. Do you take ANY PRESCRIPTIONmedications (including puffers and birth control pills)? Do you use more than one pharmacy? If yes, provide Pharmacy name + phone number of ALL pharmacies you use.4. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)? If yes provide Pharmacy name + number of ALL pharmacies you use.* Yes No Name of Pharmacy & Phone Number:* Add Remove5. Do you use or take ANY NON-PRESCRIPTION medication (including herbal remedies or vitamins)?5. Are you taking any non-prescription drugs or herbal supplements of any kind?* Yes No Please list:*6. Do you have any allergies to medications?* Yes No Not Sure Please list the medications that you are allergic to:*What happened? Rash Breathing problems/Wheezing Swelling Other Untitled*7. Do you take any medications for Osteoporosis? ( examples Risedronate, Prolia, etc.)* Yes No Not Sure If Prolia, date of last injection:* 8. Do you take 81 mg ASA, daily?* Yes No Not Sure DO NOT STOP YOUR DAILY ASA9. Do you have or have you ever had asthma?* Yes No Not Sure 10. Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure 11. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Not Sure 12. Do you have a prosthetic or artificial joint?* Yes No 13. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?* Yes No Not Sure 14. Have you ever had hepatitis, jaundice or liver disease?* Yes No Not Sure 15. Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure 16. Have you ever been hospitalized for any illnesses or operations?* Yes No Explain:*17. 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 Have you been screened for Sleep Apnea?:* Yes No Not Sure Have you been diagnosed with 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, shoulders:* Yes No Not Sure Date of replacement:* Arthritis:* Yes No Not Sure Depression / anxiety:* Yes No Not Sure Vision problems / glaucoma:* Yes No Not Sure People with intellectual/cognitive disabilities:* 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 18. Are there any conditions or diseases not listed above that you have or have had?* Yes No Not Sure Explain :19. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)* Yes No Not Sure Explain:20. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?* Yes No Not Sure When?* Where?*Name of oncologist:*20. Do you smoke or chew tobacco products?* Yes No Not Sure 21. For women only: Are you breastfeeding or pregnant?* Yes No Not Sure If pregnant, what is the expected delivery date?* Signature*Your NameYour NameYour NameYour NameConsent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*Untitled First Choice Second Choice Third Choice
