PERIODONTAL TREATMENT SRP CONSENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

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You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. *

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. *

Please read and initial the work to be done below, then read and sign the section at the bottom of the form

EXAMINATION AND DIAGNOSTIC PROCEDURES I understand that the initial visit may require radiographs in order to complete the examination, diagnosis, and treatment plan. *

DRUGS AND MEDICATION I understand that antibiotics, analgesics and other medications may cause allergic reaction causing redness, swelling of tissues, pain, itching and vomiting, and/or anaphylactic shock. I understand that the administration of local anesthetics may result in temporary or permanent paresthesia (numbness) of involved teeth, tissues, and associated structures. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain, and potential resistance to effect treatment of my condition. I accept these risks by consenting to the use of local anesthetics during my dental appointments. If I have a medical condition that necessitates antibiotic pre-medication before dental treatment, it is my responsibility to notify the dentist. I assume all responsibility for all medical consequences if the dental office is unaware of my need for pre-medication. *

CHANGES IN TREATMENT PLAN I understand that my treatment plan is only an estimate and subject to modification/changes depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment. I understand that any alterations to treatment may affect the total cost of my treatment and accept responsibility for any and all expenses regardless of third party involvement. *

PERIODONTAL TREATMENT (SRP) I understand that I have a serious condition causing gum inflammation and/or bone loss and that if left untreated can progress and can lead to further jaw bone destruction and loss of my teeth. Alternative treatment plans have been explained to me, including non-surgical cleaning, gum surgery and/or extractions I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition. *

I understand that dentistry is not an exact science; therefore, reputable practitioners cannot properly guarantee results. I acknowledge than no guarantee or assurance has been made by anyone regarding the dental treatment that I have authorized. I hereby authorize the doctors and staff members to proceed with and perform dental treatment as explained to me *

• I UNDERSTAND AND AGREE THAT I AM FULLY RESPONSIBLE FOR ANY AND ALL DENTAL EXPENSES INCURRED AT MILPITAS SQUARE DENTAL.
• I UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE COMPANY AND MYSELF. AS A COURTESY, MILPITAS SQUARE DENTAL.WILL SUBMIT CLAIMS ON MY BEHALF TO MY INSURANCE COMPANY. REGARDLESS OF ANY THIRD PARTY OR INSURANCE INVOLVEMENT, I AM RESPONSIBLE FOR PAYMENT OF ALL DENTAL FEES.
• I UNDERSTAND THAT IF MY DENTAL INSURANCE CHANGES IT IS MY RESPONSIBILITY TO NOTIFY THE OFFICE
• I AGREE TO PAY ALL ATTORNEY’S FEES, COLLECTION FEES, OR COURT COSTS THAT MAY BE INCURRED TO SATISFY THIS OBLIGATION.
• UNFINISHED TREATMENT: I UNDERSTAND THAT IF I ELECT TO DISCONTINUE TREATMENT AFTER IT HAS BEEN INITIATED, PRO RATA PAYMENT MUST BE MADE FOR PROFESSIONAL SERVICES TO THAT POINT. REFUNDS ARE NOT APPLICABLE TO RESTORATIONS AND PROSTHESIS. (refer to CALIFORNIA CIVIL CODE 1793.02 SEC. e-3).

CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of treatment and have received answers to my satisfaction. I voluntarily assume any and all possible risks including those as listed above. The fee(s) for service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize MILPITAS SQUARE DENTAL. to render any treatment necessary and/or advisable to my dental conditions including the prescribing and administering any medications and/or anesthetics deemed necessary to my treatment. *

In the event that a course of treatment recommended by a dentist is not followed, or an alternative treatment course is chosen instead of recommended treatment plan, the treatment will not be covered by a dental warranty. The applicability of the dental warranty in relation to the course of treatment followed will be indicated by dentist. Our aim at Dr. Precilyn Silvestre-Melo is to provide you with the very best possible standard of dental care, tailored to meet your specific needs, and to do this in the most timely manner and with the utmost of comfort for you. We want you to have a very positive experience with us, and gain the best treatment outcome. You adherence to these preceding terms and conditions of treatment will allow us to provide the best care for you that we can. *

PROCEDURE TO BE PERFORMED *

Date / Time *

Date

Time

PATIENT’S PRINTED NAME *

Signature *

PARENT/LEGAL GUARDIAN (if minor)

Guardian Signature

WITNESS NAME *

ASK DENTIST / RECEPTIONIST / DENTAL ASSISTANT

WITNESS TO SIGNATURE *

Please ask only receptionist, dental assistant or dentist to sign this consent form

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WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

Please read and initial the work to be done below, then read and sign the section at the bottom of the form

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