Implant surgery · CID-IMP-11 · v1.0

Inferior Alveolar Nerve Lateralization Consent

Consent for moving the lower jaw nerve aside to place implants in a severely resorbed jaw.

About 9 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

When the back of the lower jaw has lost so much height that there is not enough bone above the nerve canal for an implant, the nerve can be exposed through a window in the outer bone and held aside while implants are placed. The nerve is then released back against them. This is an advanced procedure chosen when the alternatives have been considered and found less suitable.

Material risks and limitations

The single most important risk of this procedure is a change in feeling in the lower lip, chin, and gum on the treated side.

Altered sensation — numbness, tingling, burning, or reduced feeling — of the lower lip, chin, and gum is EXPECTED immediately after surgery and is common in the months that follow. Most patients recover, usually within about six months.
In a small number of patients the change is permanent. It can affect speech, eating, drinking, kissing, shaving, and applying makeup, and there is no reliable way to repair it.
Loss of feeling is not the same as loss of movement: the muscles of the lip are supplied by a different nerve and are not moved during this surgery.
Fracture of the jaw, especially where the remaining bone is very thin. Fracture may require additional surgery, fixation, and a period of restricted diet.
Bleeding, bruising, infection, wound opening, pain, and swelling.
Implant failure, loss of the implants, or the need to remove and replace them.
The nerve may be bruised or stretched even when it is handled correctly and never cut.

Reasonable alternatives

Short implants placed above the nerve, bone grafting to add height, tilted or angled implants that avoid the nerve, implants placed only at the front of the jaw, a removable denture, an implant-retained overdenture, or no treatment.
These alternatives have been discussed. Several of them avoid the nerve entirely and therefore carry no risk of the sensory change described above.

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.

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 altered feeling in my lower lip, chin, and gum is expected after this surgery, that it usually improves over months, and that in a small number of patients it is permanent and cannot be repaired.I understand that alternatives exist which do not involve moving the nerve, that they have been explained to me, and that I am choosing this procedure with that knowledge.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-11 · v1.0 · Effective 06 Sep 2026 · Next clinical review 06 Sep 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS