Consent Form Periodontal Surgery

Patient and Doctor Information

In order to make an informed decision about undergoing a procedure, I am entitled to have certain information about the proposed procedure, the associated risks, the alternatives and the consequences of not having it performed. The Dentist has provided me with this information to my satisfaction. The following is a summary of this information. This form is meant to provide me with the information I need to make a good decision; it is not meant to alarm me.

 

Fees & Cancellations

All fees quoted for treatment prior to surgery are final and non-negotiable regardless of insurance carrier coverage. I am aware that should I require an emergency appointment outside of my regularly scheduled appointments, there may be an additional fee to be collected the day of the appointment.

 

When scheduling surgery, a non-refundable deposit will be collected at the time of booking. The remaining balance will be collected in full the day of the procedure.

 

We require ONE WEEK notice to cancel or reschedule surgical appointments. Cancellations of less than one week notice will result in a late fee.

Regarding any risks that may be associated with the proposed treatment, I understand that the following items may be relevant to my course of treatment. The risks of the procedure include, but are not limited to:

 

Patient / Guardian Signature
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