PERIODONTAL CONSENT FORM

I understand that I have periodontal (gum and/or bone) disease. The disease process has been explained to me and I understand that it is caused by bacterial toxins (poisons) and my host response to these toxins.

I realize that this disease may be painless and without symptoms, but that usually symptoms such as bleeding, swelling, or recession of gum tissue, loosened teeth, elongated teeth, bad breath, or sensitivity and soreness may be noticed. Treatment of periodontal disease may include periodontal scaling and root planning, either as a therapeutic procedure or preliminary to more extensive treatment.

The doctor has explained to me that there are certain potential risks in this treatment plan or procedure

Periodontal scaling and root planning involves the removal of calculus, bacterial plaque, bacterial toxins, diseased cementum (the outer covering of the root surface), and diseased tissue from the inner lining of the crevice surrounding the teeth. The purpose of this procedure is to reduce some of the causes of periodontal disease to a level more manageable by my individual immune system. I understand that my own efforts with home care are just as important as my professional treatment.

Consequences of doing nothing about my periodontal condition may be, but are not limited to:

Consequences of doing nothing about my periodontal condition may be, but are not limited to:

• Increased recession of gum tissue and exposure of root surfaces
• Increased sensitivity to hot, cold, or sweets; this may require further treatment, may fade with time, or may persist no matter what is done
• Increasing tooth mobility (loose teeth)
• Food may collect between teeth
• Continued infection of the gums and other supporting structures
• Loss of teeth
• Spread of infection to other sites in the body

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post treatment instructions have been explained to me.
• I had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors to perform the treatment on me.