• Discussion and Informed Consent for Nonsurgical Periodontal Treatment

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  • Facts for Consideration

    Patient's initials required
  • Benefits of Nonsurgical Periodontal Treatment, Not Limited to the Following: 

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  • Risks of Nonsurgical Periodontal Treatment, Not Limited to the Following:

    Patient's initials required
  • Consequences if No Treatment Is Administered Are Not Limited to the Following:

    Patient's initials required
  • Alternativesto Nonsurgical Periodontal Treatment, Not Limited to the Following:

    Patient's initials required
  • Discussion and Informed Consent for Anesthesia

    Local Anesthesia
  • For All Female Patients

  • For All Patients

  • Check the boxes below that apply to you:

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  • No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.

  • Should be Empty:
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