Implant surgery · CID-IMP-05 · v1.0

Failed Implant Removal and Revision Consent

Informed consent for removing a failing or failed dental implant and, where possible, rebuilding the site.

About 8 minutesRead, sign and download from your own device

Completion

0 of 17 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

A dental implant that has failed to integrate, has lost supporting bone, has fractured, or is positioned in a way that cannot be restored will be removed. Removal may involve reflection of gum tissue, use of a reverse-torque device or removal burs, and removal of a small amount of surrounding bone.

Depending on what is found at the time of surgery, the site may be grafted, left to heal before a further procedure, or receive a replacement implant in the same visit. Whether a replacement implant can be placed immediately cannot be determined reliably until the failed implant is out and the site is examined.

Expected benefits

Removal of a source of infection, inflammation, pain, or progressive bone loss.
Preservation of the remaining bone and preparation of the site for future treatment.
An opportunity to rebuild the site and, where conditions allow, to place a new implant.

Material risks and possible complications

Pain, swelling, bruising, bleeding, infection, delayed healing, or wound opening.
Loss of additional bone or gum tissue during removal, leaving a larger defect than expected and requiring grafting.
Fracture of the implant during removal, leaving a retained fragment that may require a further procedure or, rarely, be left in place if removal would cause greater harm.
Damage to adjacent teeth, implants, restorations, nerves, sinus, or other anatomy.
Injury or altered sensation of the lip, chin, or tongue; altered sensation can be temporary or permanent.
Failure of the graft or of any replacement implant, requiring repeat treatment.
The final result may not match the original plan; a different restoration, a longer timeline, or an alternative to implant treatment may become necessary.

Reasonable alternatives

No treatment, with the possibility of continued infection, bone loss, pain, or spread of infection.
Attempted treatment of the tissue around the implant without removing it, where the implant is judged salvageable.
Removal without replacement, followed by a bridge, a removable prosthesis, or leaving the space unrestored.
Referral for another opinion before proceeding.

Patient responsibilities

Provide any records, radiographs, or information available about the original implant, including where and when it was placed.
Follow all post-operative, medication, and diet instructions and attend follow-up visits.
Disclose tobacco use, diabetes control, bruxism, and antiresorptive or immune-affecting medications, all of which affect healing and re-treatment success.

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.Where and approximately when was the original implant placed?Enter “Unknown” if you do not have this information.

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 whether the site can be grafted or receive a replacement implant during the same visit cannot be determined until the failed implant is removed and the site is examined, and that the plan may change during surgery.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 17 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-05 · v1.0 · Effective 31 Jul 2026 · Next clinical review 31 Jul 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS