Implant surgery · CID-IMP-14 · v1.0

Temporary Full-Arch Teeth Acknowledgment

What to expect from the temporary set of teeth worn while your implants heal.

About 6 minutesRead, sign and download from your own device

Completion

0 of 16 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

What the temporary teeth are

The set of teeth fitted at or shortly after your full-arch surgery is a provisional — a working temporary. Its job is to let you leave with teeth, to protect the surgical site, and to let your bite, speech, and appearance be tested and adjusted before the final teeth are made. It is not the final result and is not built to last like the final result.

What to expect

The temporary is made of acrylic. It can chip, crack, break, stain, or wear, and a tooth can come off it. This is not unusual and is usually repairable.
It may feel bulky, change how you speak for a while, and need several adjustments as swelling settles.
The shade, shape, and position of the teeth will be refined for the final set. Judge appearance at the final stage, not this one.
Gum shrinkage during healing is normal and can leave a gap under the temporary that traps food. This is expected and is corrected at the final stage.

What you must do while wearing it

Follow the diet you are given. A soft diet protects the implants while they integrate; biting into hard or crusty food can break the temporary or loosen an implant.
Do not chew ice, hard sweets, nuts, or crusty bread, and do not use your front teeth to tear food.
Clean underneath it exactly as instructed, every day.
Do not smoke or vape. Nicotine measurably increases the risk that implants fail to integrate.
Call the office the same day if the temporary loosens, breaks, or an implant feels loose — do not wait for your next appointment, and do not glue it yourself.

Repairs and replacement

Adjustments and repairs during normal healing are part of your treatment. A temporary broken by not following the diet or the care instructions, or lost, may be charged for.

3. Your case, in your words

Arch fitted with the temporary (upper, lower, or both)Questions you asked about the temporary teethEnter “None” only if you have no remaining questions.

4. Confirm, then sign

I understand that the teeth fitted now are a temporary, that they are not the final result, and that their appearance and fit will be refined at the final stage.I understand that the temporary can chip, break, or loosen, and that I must follow the diet and cleaning instructions I have been given.I understand that I should call the office the same day if the temporary breaks or loosens or if an implant feels loose.I have had an opportunity to ask my treating dentist questions, and my questions have been answered in language I understand.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 16 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-14 · v1.0 · Effective 06 Sep 2026 · Next clinical review 06 Sep 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS