Form

CONSENT - PERIODONTAL DISEASE

This information is to ensure that you are aware of the existing periodontal disease (gum disease) and infection present in your mouth. It is to acknowledge that you have been informed of the existence of this disease and given a copy of the periodontal pocket charting. The consequence of nontreatment will likely result in a progression of this infection and, if it continues, eventual bone loss, loosening of teeth and the ultimate loss of teeth. This release also acknowledges that on this date at least two options for treatment were offered to you:

A nonsurgical approach to periodontal disease in which you are an active co-participant
Referral to a periodontal specialist for a surgical approach to therapy, or other treatment as deemed appropriate

Name of specialist to whom patient was referred:

First Name

Last Name

Date Of Birth

Patient / Legally Authorized Representative Signature

Date

Name if signed on behalf of the patient

Relationship