I have been informed and afforded the time to fully understand the purpose and the nature of the
bone graft surgical procedure. I understand what is necessary to accomplish the placement of the
bone graft under the gum on/or in the bone.
Dr. Safari has carefully examined my mouth. Alternatives to this treatment have been explained. I
have tried to consider these other methods, but I desire a bone graft to help secure the replaced
I have further been informed of the possible risks and complications involved with this surgery,
drugs, and the anesthesia used. Such complications include pain, swelling, infection, and
discolouration. 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 other teeth present, bone fractures, sinus penetration, delayed
healing, and allergic reactions to drugs or medications used. Other complications may include
trauma to the nerve tissue or blood vessels that may lead to loss of sensation of lip tongue check
or other tissues in the mouth or altered sensation or pain.
I understand that if nothing is done any of the following could occur: bone disease, loss of bone,
gum tissue inflammation, infections, sensitivity, looseness of teeth followed by the necessity of
extraction. Also possible are temporomandibular joint (jaw) problems, headaches, referred pains
to the back of the neck and facial muscles, and tired muscles when chewing. Also, I am aware that
if nothing is done an inability to place a bone graft or implants at a later date due to changes in
oral or medical conditions could exist.
Dr. Safari has explained that there is no method to accurately predict the gum and bone healing
capabilities in each patient following the placement of a bone graft. It has been explained that the
bone in its healing process remodels and there is no method to predict the final volume of bone,
thus additional grafting may be necessary.
It has been explained that in some instances bone grafts fail and must be removed. It also has been
explained to me lack of adequate bone growth into the bone graft replacement material could
result in failure. I have been informed and understand that 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 bone graft surgery may fail, which might require further corrective surgery or the removal of
the bone graft with possible corrective surgery associated with the removal. If the bone graft
surgery fails I understand that alternative prosthetic measures may have to be considered.
I understand that excessive smoking, alcohol, or blood sugar may affect gum healing and may limit
the success of the bone graft. I agree to follow my doctor’s home care instructions. I agree to
report to my doctor for regular 3-month examinations after completion of the treatment.
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 and 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
I hereby request and authorize Dr. Safari and his staff to proceed with the recommended bone
graft. I also approve any modifications in design, materials, or care, if it is felt this is in my best
interest. I authorize Dr. Safari and his team to do whatever they deem necessary and advisable
under the circumstances, including the decision not to proceed with the bone graft procedure.
ANY QUESTIONS OR CONCERNS?
PLEASE FEEL FREE TO CONTACT THE OFFICE AT 905 770 0099 OR 416 223 2453
Once fully read and reviewed, please make sure that the above document is filled out
appropriately. By submitting this document, we are assuming that it has been read in its
entirety. All patient signatures will be verified for authenticity in the office.