I hereby give consent to perform Scaling and Root Planing procedure(s) on me or my dependent and any such additional procedure(s) as may be considered necessary for my well-being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me, and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.

Alternative methods of treatment have been explained to me, but I wish to proceed with the Recommended Treatment described above.

I understand that there are risks and complications associated with the administration
of medications, including anesthesia and performance of the Recommended
Treatment. These potential risks and complications include, but are not limited to, the following:

1. Drug reactions and side effects.
2. Post-treatment bleeding, oozing, and infection.
3. Bruising and/or swelling, delayed healing, restricted mouth opening for several
   days or weeks.
4. Varying lengths and degrees of sensitivity.
5. Increased spacing between teeth due to removal of hard deposits.
6. Revealing of recessed gums.
7. Increased mobility of teeth.
8. As a result of the injection or use of anesthesia, there may be swelling, jaw
   muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws
   And/or facial tissues, which is typically temporary, but in rare instances, may be permanent.