Form

INFORMED REFUSAL: Periodontal Scaling and Root Planing

am aware of the gum infection and periodontal disease present in my mouth. I hereby release from liability Dr.

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

Patient signature

Witness signature

Date

INFORMED REFUSAL: Periodontal Maintenance

understand I have a serious periodontal condition (Periodontal Disease) causing gum and bone infection and/or loss of bone and that this can result in the ultimate loss of my teeth. I hereby release from liability Dr.

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

I understand that it is recommended that I have this procedure, Periodontal Maintenance, performed in

monthly intervals in order to remove the plaque (bacteria), calculus (tartar), and infective toxins (poisons) from the pocket areas that I cannot reach with brushing and flossing.

I understand that an adult Prophylaxis, typically called a "routine cleaning", will NOT address the removal of the plaque (bacteria), calculus (tartar) and infective toxins (poisons) to the base of the pockets in my mouth which range from

mm to

mm in depth.

I have carefully read the above and understand this refusal for treatment.

Patient signature

Witness signature

Date

First Name

Last Name

Date Of Birth