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I hereby request and authorize Dr. Azouz to place zirconium dental implant(s) for me, and to perform other
procedure(s) that, in his judgment, are necessary during the operation (including, but not limited to, grafting and
membrane procedures to facilitate growth of new bone).
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The effect and nature of the implantation to be performed, the risks involved, as well as possible alternative
methods of treatment have been fully explained to me. I understand that there is no guarantee, by the implant
company or Dr. Azouz that the implant procedure will be successful, and no warranty has been made by anyone as
to the result.
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I consent to the administration of local anesthetics and/or oral sedative drugs to be applied by, or under the
direction of, Dr. Azouz and his assistants, and to the use of such local anesthetics and oral sedative drugs as he
may deem advisable in my case.
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I also understand that smoking of tobacco or drinking of alcoholic beverages causes tissue destruction and will
compromise healing and the success of treatment.
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If implants have been placed in the lower jaw, I may experience some tingling or numbness on the skin or the lip
or the chin, after surgery. This can occur from pressure or compression on a nerve tract, which is deep in the
mandible. This tingling or numbness is usually temporary, but it may remain for weeks or months. If the
implant is placed in the lower back jawbone, it is possible that this tingling or numb feeling could be permanent.
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I have been given the opportunity to ask any questions I may have, before signing this form.
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I have read and understand all of the above.
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