Periodontal Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________ Chart #: ___________

Nature of Periodontal Disease

I understand that I have been diagnosed with periodontal disease, an inflammatory condition affecting the gums and bone supporting my teeth. I acknowledge that this is a serious condition that can lead to tooth loss if left untreated.

Recommended Treatment

The following treatment has been recommended:

• Scaling and Root Planing
• Periodontal Surgery
• Bone Grafting
• Soft Tissue Grafting
• Dental Implants
• Other: ________________

Treatment Understanding

I understand and acknowledge that:

1. Success of treatment depends significantly on my home care and compliance
2. Regular maintenance visits are essential (typically every 3-4 months)
3. There is no guarantee of success, even with appropriate treatment
4. Additional procedures may be necessary based on findings during treatment

Potential Risks

I have been informed of potential risks, including but not limited to:

• Sensitivity to hot and cold
• Gum recession
• Tooth mobility
• Infection
• Pain or discomfort
• Swelling
• Bleeding

Financial Agreement

I understand that:

• The estimated cost of treatment is: $__________
• Insurance coverage may be limited
• I am responsible for any portion not covered by insurance

Consent

I have read and understand this agreement. All my questions have been answered satisfactorily.

Patient Signature Date

Dentist Signature Date

Witness Signature Date