Informed Consent &

Patient Education Platform

made digital with 5thPort ®

Get up and running quickly with the industry’s

most innovative digital platform
 The 5thPort platform can help manage
®

risk, improve patient engagement and

move your practice forward.
“ 5thPort gives me and my staff peace of mind.
The videos were purposefully developed so the information delivered is
complete and consistent every time.

The 5thPort platform allows my staff and me to focus more time on direct
clinical care and counseling based on patient specific conditions.
The completely documented patient encounter and consent documents
are stored in a HIPAA compliant cloud, providing me with a greater level
of risk mitigation.

My patients love its simplicity and the convenience of securely accessing the
platform remotely before and after their procedure – they are provided with
easy-to-understand information about what they can expect, the risks of the

”
procedure and instructions for post-operative care. Rob Berube, DDS
Board-certified Oral and
Thanks to 5thPort, my practice delivers Maxillofacial Surgeon

a higher level of patient engagement.

Implementation is as easy as 1•2•3

1 Fill out a one-page form with your practice information
2 5thPort creates your branded platform in less than 48 hours
3 We train your staff on how to digitize your office workflow with
the 5thPort Platform
Contact us at info@5thPort for a free demo and start your digital
experience with the 5thPort platform!
 Documentation
Informed Consent Education Acknowledgement
5thPort Oral and Maxillofacial Surgery Associates
5 Community Drive, Suite 1
Oral & Maxillofacial Surgery Augusta, ME 04330

INFORMED CONSENT FOR DENTAL IMPLANT

Pa ent Name:  Date of Birth: 01/01/1975

This form and your discussion with your doctor are intended to help you make informed decisions about your surgery. As
a member of the treatment team, you have been informed of your diagnosis, the planned procedure, the risks, benefits,
and alterna ves associated with the procedure, and any associated costs. You should consider all of the above, including
the op on of declining treatment, before deciding whether to proceed with the planned procedure. Your doctor will be INFORMED CONSENT FOR DENTAL IMPLANT
happy to answer any ques ons you may have and provide addi onal informa on before you decide whether to sign this
document and proceed with the procedure.
Oral & Maxillofacial Surgery
1. My condi on has been explained to me as: Unrestorable tooth
2. The procedure(s) necessary to treat the condi
Pa on(s) has/have
ent Name: been explained to me and I understand
 Date of Birth: 01/01/1975
the nature of the treatment to be: Dental Implant
3. I have been informed of possible alternate methods of treatment (if any), including:
I understand Bridgethat the doctor cannot guarantee the results of the procedure or the length
and accept
4. I have been informed of and understand the poten al risks related of tomethisneeded
surgicalto procedure
complete my treatment. I had sufficient me to read this document, understand
include
the above statements, and have had a chance to have all my ques ons answered. By signing this
but are not limited to:
document, I acknowledge and accept the possible risks and complica ons of the procedure and
Pain, swelling, bleeding, infec on, bruising, delayed healing, scarring,
agree damage
to proceed.to other teeth and/or
roots that may result in the need for tooth repair or loss, loose tooth/teeth, damage to dental
If I am sedated or under general anesthesia during the procedure, I further authorize the doctor to
appliances, cracking and/or stretching of the corners of the mouth,
modifycutsthe
inside the mouth
procedure if, inorhis/her
on theprofessional judgment, it is in my best interest.
lips, jaw fracture, stress or damage to the jaw joints (TMJ), difficulty in opening the mouth or
chewing, allergic and/or adverse reac on to medica ons and/or materials;
Nerve injury, which may occur from the surgical procedure and/or the delivery of local anesthesia,
Janet Johnson
resul ng in altered or loss of sensa on, numbness, pain, or altered feeling in the face, cheek(s), lips,
chin, teeth, gums, and/or tongue (including loss of taste). Such condi ons may resolve over me, but
4/29/2019
in some cases may be permanent; Pa ent or Legal Representa ve Signature Date
An opening may occur from the mouth into the nasal or sinus cavi es;
Janet Johnson
Inability to place the implant due to the local
Printanatomy;
Pa ent orImplant failure;
Legal Representa ve Name/Rela onship

Jaw fracture;
Tina Miller
Discolora on and appearance changes of the gum ssue; Unsa sfactory cosme c result;
4/29/2019
Witness Signature (op onal) Date
Bone loss around the implant(s) and/or adjacent teeth; I understand that bone gra ing may be
necessary.
I cer fy that I have explained to the pa ent and/or the pa ent’s legal representa ve the nature, purpose, benefits,
5. I have elected to proceed with the anesthesia(s) indicated below.
known risks, complica ons, and alterna ves to the proposed procedure. The pa ent and/or pa ent’s legal
o Local Anesthesia representa ve has voiced an understanding of the informa on given. I have answered all ques ons to the best of my
knowledge, and I believe that the pa ent and/or legal representa ve fully understands what I have explained.
o Nitrous Oxide (Laughing Gas)
o
o
Mild Seda on
Moderate Seda on
Dr. Robert Cirgiry 4/29/2019
Doctor Signature Date
þ Deep Seda on (General Anesthesia)

Page 1

Page 3

Depending on the specific procedure, 5thPort dynamically 5thPort collects and

stores the patient
creates the OMSNIC* Informed Consent form.
experience, consent
Any enhancements made by OMSNIC to their consent forms
signature and consent
are automatically updated in the 5thPort platform, so your forms, securely in a
records are always complaint. HIPAA compliant
environment.
*Used with permission of OMSNIC

Increase patient satisfaction, streamline your office

workflow and reduce legal exposure with 5thPort.
 Informed Consent
Each section
of the consent
form has
individual is
date/time
stamped when
initialed

Sections can be flagged

Time-Stamped and Verifiable – all aspects of diagnosis and treatment for later discussion –
are presented in a simple format, requiring the patient’s initials which when signed, the section
are time-stamped. Patients have the ability to identify the areas they records the accurate time
want to discuss in further detail before initialing the section. and date.

Time and date stamps verify patient understanding

of all diagnosis, procedures, risks and recovery protocols.
 Educational videos
with teach back

The 5thPort platform

is personalized with
your practice’s
branding.

At the beginning of the

video, the patient is told
they will be asked a few
questions about the
information following
the presentation.

Patients and caregivers can watch or re-watch our informative

videos in the provider’s office or at home, pre- and post-visit.

The videos typically last several minutes and describe the benefits, risks and alternative
treatment options of their procedure and additional information to assist the patient
with postoperative care. Most importantly, the teach back component ensures that the
patient comprehends the information presented.

5thPort is first to verifiably engage patients before & after

the procedure in or out of the office, test comprehension with
teach back, and capture date/time stamp of videos watched.
The 5thPort platform sets a new
®

standard of care
5thPort is a healthtech company that recognized a need for a more efficient, easy-to-use
digital platform to streamline the informed consent process.

Developed with a practicing OMS specifically for OMS practices, the 5thPort platform educates
patients with easy-to-understand videos, followed by a simple comprehension quiz and digital
signature technology. As part of the informed consent process, the patient is better engaged
and more well informed. Additionally, the date/time stamped signature mitigates liability risk
by creating digital documentation of the process.

5thPort is first to:

• Verifiably engage patients before and after surgery in office or in-home setting

• Test comprehension of information presented with teach back

• Capture date/time stamp of video watches and quiz completion

• Flag individual sections of the Informed Consent form for enhanced consultation

• Capture the date/time stamp of each patient initial on the Informed Consent form

• Deliver a NEW Standard of Care for OMS practices

To learn more about the 5thPort platform, contact us at

info@5thPort.com or visit www.5thPort.com

©2019 5thPort, LLC