CONSENT FOR USE OF GRAFTING MATERIAL

CONSENT FOR USE OF GRAFTING MATERIAL FOR RIDGE PRESERVATION / AUGMENTATION

Bone loss is inevitable following extractions (performed in the past or present). Bone / Tissue grafting can lessen the extent of the bone loss and/or restore deficiencies.

GRAFTING MATERIALS:

Hydroxyapatite Graft (Sterile) - Laboratory synthesized calcium apatite used as filler for the purpose of bone growth.
Calcium Sulphate / Phosphate (Sterile) - Laboratory processed calcium material used as a filler for the purpose of bone growth
Bovine Bone Graft (Sterile) - Composite anorganic bovine-derived bone material & synthetic peptide
Allograft (Sterile) - Commercially prepared laboratory processed human donor bone
Autograft - Bone material harvested from another part of your own body
Collagen Membrane / Barrier (Sterile) - Laboratory processed purified protein barrier derived from animal (bovine/porcine/human) source
Titanium Mesh/Netting (Sterile) - Commercially prepared non-absorbing mesh to contain the graft material for a temporary period. After a short healing period, it will need to be removed.
No Graft elected

ADJUNCTIVE PROCEDURES:

I also consent for use of Adjunctive Procedures which can facilitate a more successful outcome:

Platelet Rich Fibrin - Concentrated natural fibrin clot isolated from your blood for facilitating tissue healing
Botox Therapy - Purified proteins administered to temporarily relax/reduce the damaging forces of clenching/chewing muscles

I have had the above options explained to me and have had my questions answered to my satisfaction by Doctor. I elect/consent to have the above choice(s) performed by:

Doctor: *

Participant's Name *

First

Last

Parent/Guardian Name *

First

Last

Emergency Contact Number *

Consent *

Please tick the box to agree.

Signature *

Date *