Periodontal Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: _________________

Agreement Terms

1. Treatment Understanding

I, the undersigned patient, understand that I have been diagnosed with:

• Gingivitis
• Stage I Periodontitis
• Stage II Periodontitis
• Stage III Periodontitis
• Stage IV Periodontitis

2. Recommended Treatment Plan

I agree to undergo the following periodontal treatment procedures:

• Scaling and Root Planing (Deep Cleaning)
• Periodontal Maintenance Therapy
• Follow-up visits as recommended
• Additional procedures as needed: ___________________

3. Patient Responsibilities

I agree to:

• Maintain regular periodontal maintenance appointments
• Follow prescribed home care instructions
• Inform the office of any medical changes
• Provide at least 48 hours notice for appointment cancellations

4. Financial Agreement

• I understand that the estimated cost of treatment is: $________
• I acknowledge that insurance coverage may vary
• I agree to be responsible for any amounts not covered by insurance

5. Risks and Complications

I understand the following potential risks:

• Root sensitivity
• Gum recession
• Tooth mobility
• Infection risk
• Need for additional treatment

6. Consent

I have read and understand this agreement and have had all my questions answered satisfactorily.

Patient Signature: _________________ Date: _________

Provider Signature: ________________ Date: _________

Office Use Only

Next Appointment: _________________ Treatment Phase: _________________