Informed Consent for Periodontal Treatment

Patient Name:*

Date of Birth:*

I. Recommended Treatment

I hereby give consent to Dr. Alex Mercado to perform recommended treatment 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 the 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.

II. Treatment Alternatives

Alternative methods of treatment have been thoroughly explained during my exam. All of the risks, benefits and options have been provided, but I wish to proceed with the recommended treatment described above.

III. Risks and Complications

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 andcomplications, include, but are not limited to, the following:
1.) Tooth sensitivity;
2.) Pain from treatment;
3.) Infection;
4.) Swelling;
5.) Dark spaces between teeth where there is no longer any gum tissue;
6.) Changes in how long my teeth appear (due to re-contouring);
7.) Gum tissues may shrink or recede. This change may make some previous dental restorations(i.e., crowns, fillings) more noticeable and the restorations may need to be replaced for cosmeticpurposes;
8.) Loss of bone or tissue graft;
9.) Possible involvement of the nerves of the lower jaw resulting in temporary or permanent tinglingof the lower lip, chin, tongue or surrounding structures;
10.) As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tendernessor even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which istypically temporary, but in rare instances, may be permanent;
11.) Future bone or tooth loss.

Signature:*

Patient/Parent/Guardian Clear

Date:*

Relationship (if patient a minor):

Witness (signature):

Clear