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Implants Consent

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 Zirconia Implant Consent

  • Informed Consent: Zirconium Implant

  • I hereby request and authorize Dr. Wall 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).

    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. Wall that the implant procedure will be successful, and no warranty has been made by anyone as to the result.

    I consent to the administration of local anesthetics and/or oral sedative drugs to be applied by, or under the direction of, Dr. Wall and his assistants, and to the use of such local anesthetics and oral sedative drugs as he may deem advisable in my case.

    I also understand that smoking of tobacco or drinking of alcoholic beverages causes tissue destruction and will compromise healing and the success of treatment.

    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.

    I have been given the opportunity to ask any questions I may have, before signing this form.

    I have read and understand all of the above.


  • These items may change, depending on what is found clinically, and additional procedures may be required.

    I understand the risks, benefits, costs and limitations associated with the procedure(s) outlined and explained above, and I agree to proceed with the proposed treatment.

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  • How can you help the success of your zirconia dental implant?

  • Your one-piece Z-Look3 implant made of zirconia protrudes into the oral cavity after implantation and is exposed to pressure from your tongue, cheek and chewing. These forces can delay bone healing in the jawbone or may lead to loss of the implant. Dr. Wall has provided you with a specially fabricated temporary denture/protective device, which prevents negative factors for the success of your treatment.

    Your cooperation when wearing the temporary restoration/protective device is essential for the successful healing of your implant. Please wear the temporary denture 24 hours a day. If you have a removable denture, please remove this only to brush your teeth or clean the denture.
  • Conduct after surgery

  • Please take the prescribed medication and painkillers according to Dr. Wall’s instructions. In addition to alleviating pain, these medications may also reduce swelling around the surgical site.

    Please avoid absolutely consumption of alcohol, coffee, and nicotine. Please follow these post operative instructions you received after surgery

    Please avoid hot foods and drinks directly after the implant surgery.

    Please avoid physical effort such as heavy physical work or sports for 2-3 days after the surgery.
  • Oral hygiene

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

Schedule Your Appointment with the Holistic Dentist

Every service we offer is aimed at improving your overall health. We offer several procedures that eliminate the need for surgical incisions, reducing your discomfort, downtime, and the need for multiple visits. Call our office to schedule your consultation today.