Implant surgery · CID-IMP-03 · v1.0

Full-Arch Implant Surgery Consent (All-on-4, All-on-6, All-on-8)

Informed consent for full-arch implant treatment, including any immediate-load fixed provisional teeth placed the same day.

About 10 minutesRead, sign and download from your own device

Completion

0 of 19 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Patient full legal name *Date of birth *Email *Phone *

Treating dentist

Dr. Jain & Dr. Gupta

Treating office *Signer full legal name *Enter the patient’s name when the patient is signing. An authorized representative must enter their own name.Relationship or authorityRequired when someone other than the patient signs.

2. What you are agreeing to

Proposed treatment

Full-arch treatment replaces all of the teeth in one or both jaws with a fixed prosthesis supported by several implants. It commonly includes removal of remaining teeth, reshaping of bone to create a suitable foundation, placement of the number of implants the treating dentist determines the anatomy requires, and connection of a fixed provisional prosthesis.

Where bone volume, implant stability, or bite forces do not support it, immediate fixed teeth may not be possible and a removable or staged approach may be required instead. The number and position of implants, the decision to load them immediately, the materials, and the timing of the final prosthesis are individualized by the treating dentist and recorded in the treatment plan.

Expected benefits

Replacement of a failing or absent dentition with fixed teeth that are not removed by the patient.
Improved chewing ability, speech, and appearance compared with a removable full denture.
Preservation of stimulation to the bone that supports the implants.

Material risks and possible complications

All risks of extraction, bone recontouring, and implant placement, including pain, swelling, bruising, bleeding, infection, delayed healing, and wound opening.
Failure of one or more implants to integrate, requiring removal, additional grafting, replacement implants, or conversion to a different prosthetic plan.
Loss of the immediate fixed provisional prosthesis if implant stability is inadequate, with a period in a removable temporary appliance.
Injury or altered sensation involving lips, chin, tongue, or nerves; altered sensation can be temporary or permanent.
Sinus or nasal complications in the upper jaw, including membrane perforation or an oral-sinus communication.
Fracture, wear, chipping, staining, or loosening of the prosthesis, abutments, or screws; components are expected to require repair, replacement, or relining over time.
Changes in speech, lip and cheek support, saliva control, or the appearance of the smile line; a visible transition between the prosthesis and gum tissue may be present.
Food trapping and the need for specific daily cleaning technique; inadequate hygiene can cause inflammation and bone loss around implants.
Bite adjustment, prosthesis removal for maintenance, and long-term professional follow-up are required and are not optional.

Reasonable alternatives

No treatment, with continued deterioration of the remaining teeth, bone, and function.
A conventional complete denture or an implant-retained removable overdenture.
Retaining and treating selected natural teeth where they are restorable.
A different implant number, staged rather than immediate loading, grafting first, or referral for another opinion.

Patient responsibilities

Follow the soft-diet instructions for the full period directed after surgery; biting hard foods too early is a leading cause of early implant failure.
Complete every scheduled follow-up, adjustment, and professional maintenance visit for as long as the prosthesis is in service.
Perform the daily cleaning technique demonstrated by the team, including cleaning underneath the prosthesis.
Disclose tobacco use, uncontrolled diabetes, clenching or grinding, and any medication changes, each of which materially affects the outcome.

3. Your case, in your words

Treatment, tooth number(s), or area discussed with your dentistUse the wording from your treatment plan when available.Questions you asked or information you want your dentist to addressEnter “None” only if you have no remaining questions.Patient-specific risks or special considerations discussedFor example: medications, allergies, smoking, bone quality, nerve or sinus proximity.Arch or arches being treatedFor example: upper only, lower only, or both.

Has your dentist told you to expect fixed provisional teeth on the day of surgery?

Immediate fixed teeth depend on implant stability measured during surgery and cannot be guaranteed in advance.

YesNoNot sure / not applicable

4. Confirm, then sign

I have reviewed this form and understand the proposed treatment, its expected benefits, its material risks, reasonable alternatives, and the likely consequences of no treatment.I have had an opportunity to ask my treating dentist questions, and my questions have been answered in language I understand.I understand that this form supports—but does not replace—the informed-consent discussion with my treating dentist, and that I may withdraw consent before treatment.I understand that fixed teeth on the day of surgery depend on implant stability found during the procedure, that the plan may change during surgery, and that the provisional prosthesis is temporary and will be replaced by the final prosthesis at a later appointment.I understand that a full-arch prosthesis requires lifelong daily cleaning and professional maintenance, and that repairs, adjustments, and eventual component replacement are expected rather than exceptional.I agree to sign this form and receive it electronically. I understand this agreement applies only to this form, and that I can complete this and any other form on paper instead — completing forms on paper does not affect my treatment, my fees, or my care in any way.I understand that I may withdraw my agreement to sign electronically at any time before I sign by simply not signing and asking the office for a paper copy, and that after signing I may ask the office for a paper copy at no charge.I understand that I need a current web browser and a device able to open and save a PDF file, that I should download and keep the PDF this form produces, and that I can ask the office to print or re-send my signed form at any time.I intend my drawn or typed signature to be my electronic signature on this form, and I am signing it myself.

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Completion

0 of 19 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Need help? Call the office before signing. A patient form should document a conversation, not replace one.

Who is responsible for this document

Responsible clinicians

Dr. Sambhav (Sam) Jain, DMD, MS
Lead Implant Dentist & Founder · CA Dental License #50472
Dr. Arpana Gupta, DDS, MDS
Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

Fremont
3381 Walnut Ave, Fremont, CA 94538
Phone (510) 574-0496 · Fax (510) 574-0499
San Francisco
4318 Geary Blvd, Suite 201, San Francisco, CA 94118
Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-IMP-03 · v1.0 · Effective 31 Jul 2026 · Next clinical review 31 Jul 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS