Lester M. Lubitz,
D.D.S.
On-Line Forms
I, _______________________________, have been informed that the purpose of this dental implant procedure is to provide support for a denture, bridge or crown. I consent to the surgical insertion of these implants in my jaw by Dr. Lester Lubitz or Dr. Richard Lamping. At present, we cannot predict how long dental implants will provide service in the oral cavity. I understand in rare cases it may be impossible to place the implant after the surgical site is exposed. In this case the incision will be closed and nothing will be done. I understand that in the event the implant fails, it will be removed through a second surgical procedure. I understand that there will be no refund of the fees in the event of failure. It has also been explained to me that once the implant is inserted the entire dental treatment plan, including my personal oral hygiene, must be followed and completed on schedule. If this schedule is not carried out, the implant may fail. I understand that Dr. Lester Lubitz or Dr. Richard Lamping is responsible for the surgical insertion of the implants. I understand that my restorative doctor will make the prosthetic reconstruction. I also understand that swelling, infection, bleeding and/or pain may be associated with surgical procedure or may occur during the life of the implant. When implants are placed in the lower jaw numbness of a temporary or permanent nature may occur in the tongue, lip(s), chin or gum. When implants are placed in the upper jaw, sinus involvement may occur. When implants are placed in close proximity to other teeth it is possible to damage an adjacent tooth. I understand smoking decreases the probability of implant success. I also understand and agree that I must return for appropriate post-operative care and evaluation as outlined by Dr. Lester Lubitz or Dr. Richard Lamping.
The doctor has discussed the possibility of alternative procedures and offered to answer any of my questions concerning this procedure.
I hereby consent to and request that Dr. Lester Lubitz or Dr. Richard Lamping place dental implants in my mouth for the purpose of dental restoration..
Date:_____________Signature:___________________________________________________
Date:______________Witness:____________________________________________________
I have explained to ___________________________________the implications involved in the use of dental implants.
__________________________________acknowledges that no guarantees or promises have been made concerning the results of these procedures.
Date:__________________Signature:_______________________________________________