INFORMED REFUSAL: Periodontal Scaling and Root Planning
his/her associates, hygienists, employees, and agents from any injury I may currently, or in the future, suffer as a result of my refusal to proceed with periodontal treatment or referral as recommended.
The recommended treatment plan, alternative treatments, and the benefits and risks involved have been fully explained to me to my satisfaction and I have had all of my questions answered. Inadequate or non-treatment may result in the progression of my gum infection and periodontal disease with the possible loss of gum tissue, bone, and teeth. My gum infection and periodontal disease may have adverse effects on my total body health. I fully understand these consequences and am willing to assure all of the risks involved.
The consequences of doing nothing about my periodontal condition may be, but are not limited to: 

  • Pain and soreness
  • Systemic problems
  • Possible eventual tooth loss
  • Worsening of the disease with increased bone loss
  • Increased infection
  • Bleeding

I have carefully read the above and understand this refusal for treatment
INFORMED REFUSAL: Periodontal Maintenance
his/her associates, hygienists, employees or agents from any injury I may currently, or in the future suffer as a result of my refusal to proceed with periodontal treatment or referral.
I understand that by NOT undertaking the recommended dental procedure called Periodontal Maintenance, it may have future adverse effects on my periodontal condition resulting in possible tooth loss.
The consequences of doing nothing about my periodontal condition may be, but are not limited to:

  • Bleeding
  • Increased infection
  • Worsening of the disease with increased bone loss 
  • Possible eventual tooth loss
  • Systemic problems
  • Pain and soreness
monthly intervals in order to remove the plaque (bacteria), calculus (tartar), and infective toxins (poisons) from the pocket areas that I cannot reach with brussing and flossing.
mm in depth.
I have carefully read the above and understand this refusal for treatment.