Inital Hygiene Therapy Consent Form

I, NAME , consent to having periodontal treatment performed byPerio Specialty Group (Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. RobertStraga, Dr. Farzan Ghannad) or members of their staff. I understand that periodontal disease iscaused by organized bacterial deposits and requires a joint effort between patient and therapist toreduce the number of bacteria. I understand that periodontal treatment is normally divided intothree phases:

1. An initial phase to reduce inflammation and tooth mobility.

2. A maintenance phase (3-6 month cleanings) to prevent disease recurrence

3. A surgical phase may be required to repair the damage done by periodontal disease.

I understand the number of phases of treatment that I will require will be determined by my progress as assessed by Perio Specialty Group (Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad I further understand that successful treatment depends on how advanced the disease is initially. I understand that the extraction of certain teeth may be necessary when the disease is advanced or if these jeopardize other surrounding teeth. I understand that I will be called every few months for cleanings during my active treatment, surgical treatment and maintenance treatment and that a fee may be charged for appointments cancelled without 48 hours notice.

Signature of Patient (parent or legal guardian)

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Date