I hereby authorize (hereinafter called Doctor and/or
Hygienist) to perform Non-Surgical Periodontal Therapy (Scaling and Root Planning)
upon:
The Doctor had advised me that the diagnosis indicates I suffer from a condition known
as Periodontitis (Periodontal Disease).
I have been informed that the purpose of this treatment is to improve my periodontal
condition by removing bacterial plaque and calculus (calcified plaque) found in the
periodontal pocket(s) and on the root surface(s). This procedure is effective in the
management of Early to Moderate Periodontitis, but
may
not be a definitive treatment,
especially in deep pocketing sites. The Doctor and/or Hygienist will re-examine the
periodontal pocket site(s) at the follow-up appointment (4 wks after srp) to determine
the need for further
treatment.
Further, I have been informed that other possible alternative and/or supplemental
methods of treatment exist to include, but are not limited to: prophylaxis (cleaning above
the gum line) alone, Antibiotic therapy with topical or systemic agents, occlusal
adjustment (selective grinding of the teeth), and/or tooth extraction (removal).
Post-operative risks of the proposed treatment include, but are not limited to: swelling;
infection; tooth sensitivity; pain; restricted mouth opening for several days, weeks,
months, or longer; paresthesia (numbness) of the jaw or gum nerves which may persist
for several weeks, months, or in remote instances, permanently; gum recession
(shrinkage, teeth appearing to be longer than before); temporary, or in rare instances,
permanently; gum recession (shrinkage, teeth appearing to be longer than before);
temporary, or in rare instances, permanent interferences with phonetics (speech sounds);
clicking or pain of the temporomandibular joint (jaw joints); tooth sensitivity to hot or
cold for days, weeks, months, or on occasion permanently; transient, or in some
instances permanent tooth mobility (looseness) in selected areas; food lodging between
the teeth after meals, requiring cleaning devices such as floss for removal; and unesthetic
exposure of crown (cap) margins.
I further understand that if no treatment is rendered, my present periodontal condition
will worsen and may result in tooth loss.
I know the practice of dentistry is not an exact science and that reputable Practitioners
cannot guarantee results.
No guarantee, warranty or assurance has been given to me by anyone that the proposed
treatment will be successful to my complete satisfaction. Due to individual patient
differences, there exists a risk of failure, relapse, selective re-treatment, or worsening of
my condition to include the possible extraction of certain involved teeth despite the best
of care. However, it is the Doctor’s opinion that therapy will be helpful, and that any
further loss of supporting tissues or bone would occur sooner without the recommended
treatment.
I understand that long-term success requires my long-term continued performance of
mechanical plaque removal (oral daily homecare) and my availability for periodic
maintenance visits (recall professional care).
I Do Do Not consent to photographs of my oral and facial structures and
their publications for educational and scientific purposes.
I am executing this Authorization and Informed Consent to Non-Surgical Periodontal
Therapy (Scaling and Root Planning) on behalf of .
In so doing, I have advised the Doctor and/or Hygienist that I am the patient’s guardian
(or closest available relative). As such, I am authorized to execute this consent on
his/her behalf.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.
THE EXPLANATION THERIN REFERRED TO OR MADE AND ALL NONAPPLICABLE
PARAGRPHS, IF ANY WERE STRICKEN BEFORE I SIGNED.
I CONSENT TO THE FOLLOWING TREATMENT: