Note:  This form is designed to enlist your patient’s cooperation in continuing care for implants that normally require long-term follow-up.  It is advisable to introduce this form at an early consultation visit, often as part of the consent discussion.  It is recommended that the patient be given a copy of the signed form and that another copy be sent with each appointment notice.  When patients see this agreement, signed in their own handwriting, they are more likely to cooperate.  The outcome is better quality care and better protection from possible charges of abandonment.
==================================================================
AGREEMENT FOR SHARED RESPONSIBILITY FOR CONTINUING CARE OF IMPLANTS

Patient’s Name:                                                                                                                               
Address:                                                                                                                                           
                                                                                                                                                           
Telephone:                                                                                                                                        

Name and telephone of alternate person to contact if I am not at the above number:             
                                                                                                                                                           

Your diagnosis and treatment includes placement of                   implants in (list areas)          
                                                                                                                                                           

I acknowledge that Dr.                                              has advised me of the importance of returning for long-term follow-up which, if not done, may invite chronic infection or other disease of tissues which support my implants, and which could lead to loss of the implant(s) together with the denture, crown or bridge which is supported by them.

I understand that I also must maintain regular maintenance visits with the doctor who placed the dental restorations on the implants, recognizing that abnormal wear or stress on those appliances may also lead directly to implant failure or loss.

I agree to comply with regularly scheduled exams when notified by this office, understanding that I may choose a convenient appointment, but not postpone care beyond a reasonable time.  When notified of my appointment, I will call to confirm as soon as possible.

Implants require continuing follow-up, sometimes for years, in order to assure maintenance of bone and soft tissue support.

I also understand that if I feel there are adverse changes in my symptoms or condition between scheduled visits, I should notify this office immediately.