Periodontal Treatment Agreement and Consent Form

This agreement is entered into between _____________________ and Teeth Hub Dental Clinic for the provision of Root Canal Treatment.

I hereby consent to and authorize the performance of periodontal treatment procedures by Teeth Hub Dental Clinic. I understand that the following procedures may be recommended as part of my periodontal treatment plan:

1. Non-Surgical Scaling and Root Planning:
   • Description: Removal of plaque and calculus from above and below the gumline, smoothing of the root surfaces to promote healing and prevent progression of periodontal disease.
2. Surgical Periodontal Procedures and Root Planning:
   • Description: Surgical interventions aimed at treating advanced periodontal disease, which may involve techniques such as pocket reduction surgery, gum grafts, or bone regeneration.
3. Periodontal plastic or Perioplastic Surgery:
   • Description: Advanced surgical procedures involving the reshaping of gum tissue, bone, or other supportive structures to restore periodontal health.

I acknowledge that the risks, benefits, and alternatives of each procedure have been explained to me by [Dentist/Periodontist’s Name] or a designated representative. I have been given the opportunity to ask questions and have received satisfactory answers regarding the procedures, potential risks, and expected outcomes.

I understand that while these procedures aim to improve periodontal health, there are inherent risks and complications, which may include but are not limited to infection, swelling, bleeding, and possible need for further treatment.

I acknowledge that no guarantees have been made regarding the success or outcomes of these procedures due to individual variations in healing and response to treatment. I consent to the administration of local anesthesia and any necessary medications during the procedures.

I understand that I have the right to withdraw my consent at any time before or during the procedures. I certify that I have provided an accurate and complete medical history, including any allergies, medications, and previous dental treatments.

I have had the opportunity to review and understand the fees associated with the proposed treatment plan, and I agree to be responsible for these fees.

I hereby consent to the proposed periodontal treatment plan and authorize the Dentist/Periodontist and their staff to perform the necessary procedures.I do not agree on some of the terms and condition. (please contact us to address your concern)

Patient's name*:

Witness' name (if applicable):

Date*:

* Denotes required field