Informed Consent for Periodontal Therapy

As a patient, you have the right to be informed of your condition as well as the possible consequences of not completing the recommended treatment. After discussing the treatment needed, it is your decision as to whether you wish to undergo the recommended procedures at this office or to seek treatment by a periodontist. Nonsurgical periodontal therapy at this office consists of debridement, and/or quadrant scaling and root planning, and Oral Hygiene Instructions. You also have the right to be informed that surgical intervention may be necessary to ensure adequate bone levels, gingival tissue health, and an overall healthy environment in your mouth.

 

Patient's Statement of Treatment Choice

 

I have been advised that I have periodontal disease. I understand the success of the treatment depends on keeping routine hygiene appointments and following the oral hygiene instructions given to me. I am aware that surgical intervention may be necessary if non-surgical therapy is not successful.