Periodontal Treatment Authorization Form

I, _________________________________ (Patient Name), hereby authorize Dr. _________________ and staff to perform the following periodontal treatment procedures:

Proposed Treatment

• Comprehensive periodontal evaluation
• Scaling and root planing
• Periodontal surgery
• Bone grafting
• Soft tissue grafting
• Dental implant placement
• Other: _________________________

Understanding and Acknowledgment

I understand that:

1. The purpose of periodontal treatment is to treat and help control my periodontal disease and to help save my natural teeth.

2. The proposed treatment has been explained to me, including:

   • The nature of the procedure
   • Expected benefits
   • Material risks
   • Alternative treatment options
   • Consequences of non-treatment

3. Success of the treatment depends on:

   • My compliance with home care instructions
   • Keeping scheduled maintenance appointments
   • Following recommended dietary and lifestyle modifications

Financial Responsibility

I acknowledge that:

• I am responsible for payment of all services rendered
• I have been informed of the estimated cost of treatment
• Insurance benefits have been explained to me (if applicable)

Consent

I certify that I have read and fully understand this authorization form. I acknowledge that my questions have been answered to my satisfaction.

Patient/Guardian Signature

Date

Witness Signature