Periodontal Refusal Form

I am being provided this information and refusal form so I may fully understand the treatment recommended for me and the consequences of my refusal. I understand that I may ask questions I wish regarding the recommended treatment. This recommendation is based on visual examination, periodontal probing and charting, x-rays, and on my dentist’s knowledge of medical and dental history.

I have been informed that periodontal diseases are infections that affect the tissues and bone that support teeth. I have been informed that other factors can affect my periodontal disease and its progression, including the condition of my dental restoration, certain diseases such as diabetes and heart disease.

NATURE OF THE RECOMMENDED PERIODONTAL TREATMENT

The intended benefit of this treatment is to improve the health of my gums and teeth and try to retain my natural teeth as long as possible.

RISKS OF NOT HAVING THE PERIODONTAL TREATMENT

I understand that complications to my teeth, mouth and or/ general health may occur if I DO NOT proceed with the recommended treatment. These complications include:

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