I authorize Dr Ahmed and/or such assistants as may be selected by him to assist during surgery to reconstruct the lost bone volume and/or place implants in the area outlined below.

I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are thrombophlebitis (inflammation of the vein), injury to teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medications used, etc.

I understand that if nothing is done, further bone volume loss will occur, and this may lead to an inability to place implants at a later date.

My doctor has explained that there is no method to predict accurately the gum and the bone healing capabilities in each patient following the placement of the implant and/or bone graft.

I have been informed and understand that the practice of dentistry is not an exact science, no guarantees or assurances as to the outcome of the results of treatment or surgery can be made. I am aware that there is a risk that the planned surgery may fail, which might require further corrective surgery.

I have been informed that the doctor may be placing bone grafting materials into the surgical site. These materials will either be harvested from a second surgical site within my mouth (autogenous bone) and/or come from a donor individual (allograft). If they come from a donor individual no guarantee can be made that the allograft or xenograft is 100% free of disease. I absolve the doctor of liability for manufacturers defects in any product used during treatment.

I understand that smoking, alcohol, or blood sugar may affect gum healing and will affect the success of the implant surgery. I agree to follow my doctor's home care instructions. I agree to report to my doctor for regular examinations as instructed.

It has been offered and recommended to me that I consider oral moderate sedation for this procedure. I agree to the type of local anesthesia, depending on the choice of the doctor.

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, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.

I consent to photography, filming, recording, x-rays, and additional professional staff observing the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed.

I agree to notify the doctor's office of any and all changes to my address and /or telephone number within a reasonable time frame (two to four weeks).

I fully understand the contemplated procedure, surgery, or treatment conditions and that further conditions may become apparent and which may warrant, in the judgment of the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modifications in design, materials, or care, if it is felt this is for my best interest. If an unforeseen condition arises in the course of treatment which calls for the performance of procedures in addition to or different from that now contemplated, I further authorize and direct my doctor, associate or assistant, to do whatever they deem necessary and advisable under the circumstances, including the decision not to proceed with the surgical procedure.

I certify that I have read, have had explained to me and fully understand the foregoing consent to surgery, drug and anesthetic procedures and that it is my intention to have the foregoing carried out as stated. I have been advised that information concerning the longevity of the particular graft to be used is not available. However, I have discussed this as well as the nature of the bone graft product to be used and I consent to the procedure knowing its risks and limitations.