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CONSENT FOR SCALING AND ROOT PLANING
Patient Information:
Name: __________________________________________
Date of Birth: _____________________________________
Consent for Dental Treatment
I, the undersigned, hereby give consent to Dr. ___________________________ to perform Scaling and Root Planing on: ______________________________________ (“Treatment”) on me or my dependent. I understand that unforeseen conditions may arise during the procedure that could necessitate additional or alternative treatments, and I authorize such procedures as deemed necessary by my dentist.
I acknowledge that the nature, purpose, and expected outcomes of the recommended Treatment have been explained to me. I understand that no guarantees or promises have been made regarding the final results.
Alternatives to Treatment
I have been informed about alternatives to the recommended Treatment, including no treatment, which could lead to the progression of gum disease, tooth loss, or other complications. I understand the potential risks of choosing not to proceed.
Potential Risks and Complications Related to Scaling and Root Planing
I understand that scaling and root planing procedures carry certain risks and complications, which may include, but are not limited to:
Acknowledgment and Consent
I confirm that:
By signing below, I consent to the performance of the Treatment as described above.
Signature:
Patient/Parent/Guardian: _____________________________________
Date: ________________________________
Relationship (if signing for a minor): ___________________________________
Proper documentation is essential in modern dental practices, particularly for procedures like scaling and root planing. A well-crafted consent form protects both patients and practitioners while ensuring treatment understanding. This article provides dental professionals with an updated scaling and root planing consent form template for 2025, highlighting key components and best practices.
Scaling and root planing (SRP), commonly known as deep cleaning, requires specific patient consent due to its invasive nature and potential for discomfort. A comprehensive consent form serves multiple purposes: it educates patients about the procedure, outlines potential risks, and provides legal protection for your practice.
According to the American Dental Association, dental professionals must obtain informed consent before performing procedures like SRP to maintain ethical standards and minimize liability risks. Research shows that patients who understand their treatments are more likely to follow post-procedure care instructions and report higher satisfaction.
A properly structured consent form should include several critical sections to ensure it's both legally sound and patient-friendly:
Begin with a clear, jargon-free explanation of scaling and root planing. Include what the procedure entails, why it's necessary, and the expected outcomes.
"Scaling and root planing is a deep cleaning procedure performed below the gumline to remove bacterial plaque and tartar from the tooth roots. This procedure aims to treat periodontal (gum) disease by cleaning the roots of your teeth and helping gum tissue heal and reattach to tooth surfaces."
Transparently outline potential risks alongside the benefits of the procedure. Common risks include temporary discomfort, sensitivity, bleeding, and swelling. Benefits include reduced inflammation, pocket depth reduction, and prevention of disease progression.
Provide information about alternative treatment options, including the consequences of refusing treatment. This section demonstrates that patients have been fully informed about all available options.
Include detailed post-procedure care guidelines to support healing and maximize treatment effectiveness. This might include medication instructions, oral hygiene practices, and dietary recommendations.
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While using a template provides a solid foundation, customization is essential to match your specific practice needs and state regulations. Consider consulting with a dental attorney to ensure your consent form meets all local legal requirements.
Your consent form should reflect your practice's communication style while maintaining all necessary legal elements. The language should be accessible to patients with varying education levels (generally aim for 8th-grade reading level).
A comprehensive, up-to-date scaling and root planing consent form is essential for dental practices providing periodontal care. By including clear procedure descriptions, risks and benefits, alternatives, and aftercare instructions, you protect both your patients and your practice.
Looking to streamline your dental documentation process beyond consent forms? Try Denota's AI-powered dental notes solution to reduce administrative time and focus more on providing exceptional patient care.
*Disclaimer: This document is a sample form provided by Denota and should not be considered medical or legal advice. Because the details of your situation may vary, and the laws in your jurisdiction may differ, you are advised to consult your attorney or other qualified professionals if you have any questions related to legal or medical responsibilities, state or federal laws, contract interpretation, or any other legal matters.
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