Periodontal Treatment Informed Consent Form

Patient Information

Name: _________________________ Date: _________________ Date of Birth: __________________ Chart #: _______________

Nature of Periodontal Disease

I understand that I have been diagnosed with periodontal disease, which is an infection of the gums and bone that support the teeth. I have been informed that this condition may result in the loss of my teeth and/or negative systemic health impacts if left untreated.

Recommended Treatment

The following treatment has been recommended (check all that apply):

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

Potential Risks and Complications

I understand that the following complications may occur:

• Post-operative pain, swelling, and discomfort
• Bleeding that may last several hours
• Tooth sensitivity to hot, cold, or sweet stimuli
• Gum recession and exposed root surfaces
• Infection requiring additional treatment
• Changes in bite or tooth position
• Tooth mobility or loss

Alternative Treatments

I acknowledge that alternative treatment options, including no treatment, have been explained to me, along with their risks and benefits.

Post-Treatment Care

I understand that successful treatment depends on:

1. Proper home care and oral hygiene
2. Regular periodontal maintenance visits
3. Compliance with recommended follow-up schedule
4. Cessation of tobacco use (if applicable)

Financial Responsibility

I understand that I am responsible for payment of the agreed-upon fees associated with my treatment and that this consent does not include any financial agreements.

Consent

I certify that I have read and fully understand this consent form. All my questions have been answered satisfactorily, and I agree to proceed with the recommended treatment.

Patient/Guardian Signature Date

Dentist Signature Date

Witness Signature Date