One of the most neglected areas in dentistry is that of providing patients with a detailed explanation of the treatment they will be receiving and the fees they will be charged. This formserves both as a notice that complies with the Dental Boards requirement and to obtain informed consent for teledentistry. /Outlines 14 0 R Fax: 1.901.761.3775 Last updated February 1, 2021 . While it was expected that the 2000 edition of the ADA's Current Dental Terminology-3 book would change the description for D4910 to include a periodic oral evaluation (recall exam), this did not happen. In addition, the patient undergoes a consistent "perio maintenance" experience which is not at all like a D1110-Adult Prophylaxis exam. >> 32 0 obj 4. Root planing smooths the root surfaces. % << Create your signature and click Ok. Press Done. /LastChar 121 << INFORMED CONSENT FOR PERIODONTAL FLAP SURGERY . /Encoding /Identity-H /Leading 42 If this happens, it is usually because they were already loose or attached to unhealthy tooth. /FontBBox [ -628 -210 2000 728 ] Periodontal Status Form, 8-1/2" W x 11" H, 100/Pkg . 0000003274 00000 n The American Academy of Periodontology has developed parameters on periodontal maintenance that details what procedures should be included in a maintenance visit. 20 26 . Insurers usually pay for two "cleanings" of any type per year, and they include D4910 under that heading. Emitrr talks about dental treatment consent for all types of treatment: Implant, Oral, Denture. An overview of the Cal/OSHA requirements for a dental practice to have an air compressor/tank permit. Your IP: endobj 0 /XHeight 250 >> Hygienists usually perform periodontal-maintenance procedures on patients who have undergone root-planing procedures or perio surgery. /MaxWidth 2614 Pt advised that good glycaemic/blood sugar control is paramount to preventing progression of periodontitis.Smoking cessation? By signing below: I certify that I have read and fully understand this consent form. 167.86.107.28 The informed- consent process and fee estimate do not have to be done by the hygienist. Why is it necessary? Toggle navigation. 0000000017 00000 n Periodontal maintenance refers to a procedure carried out to clean your teeth thoroughly. Use this form to explain the need for your patients to have periodontal maintenance covered every three months in your practice. Each visit involves scaling, polishing, and your dental hygienist will also check the depth of your perio pockets. All rights reserved. endobj Sample informed consent forms to aid in the face-to-face informed consent discussion between the dentist and patient. 0000011588 00000 n Contact Us. /Widths 25 0 R regular dental checkups and cleansing after treatment is complete. As a result of periodontal root planing and curettage: a. Follow the step-by-step instructions below to design your periodontal charting pdf: Select the document you want to sign and click Upload. << Patients who are unable to discern any difference between the two procedures except for the fee are taking their issues to both state boards and the malpractice court. Toothbrush: Demonstrated modified Bass technique in the mouthTepe sizes chosen:Other aids: Flossettes? Plaque distribution chart %Advice given to improve residual plaque deposits, patient motivated and re-demonstrated technique intraorally (shown in the mirror). You can email the site owner to let them know you were blocked. 0000011253 00000 n Advised use of analgesia as required. /AvgWidth 401 /H [ 1109 232 ] 0000011894 00000 n Periodically check local websites as rates in these cities could change at any time. If periodontitis isn't advanced, treatment may involve less invasive procedures, including: Scaling. >> PATIENT LOGIN. This month we feature the periodontal maintenance necessity form. Advised to improve plaque levels to support periodontal therapyPatient shown how to use interdental brushes properly and advised sizes:Discussed referral to periodontal specialist. A recent CDC report 1 provides the following data related to prevalence of periodontitis in the U.S.: 47.2% of adults aged 30 years and older have some form of periodontal disease. If plaque is not removed, it can harden and form calculus (tartar) that can exacerbate the periodontal problem. A progress-notes form that includes all details of the appointment [For a complimentary sample of such forms, call (800) 548-2164.]. Carol D. Tekavec CDA, RDH, is the author of a new insurance coding manual, the Dental Insurance Coding Handbook-2000, designer of a dental chart, and a national lecturer with the ADA Seminar Series. /DescendantFonts 33 0 R xref The frequency will be determined by the type of periodontal disease you have, the type of periodontal treatment you have had in the past, how you have responded to those treatments, and how quickly you accumulate plaque. All rights reserved. For practical purposes, the perio-maintenance appointment might follow a consistent format utilizing four effective chart forms or computer screens. Periodontal maintenance is a comprehensive cleaning performed every 3-4 months to remove plaque and tartar buildup from the teeth. Click to reveal /L 86318 This discussion should be documented in the patient record. 1201 K Street, 14th Floor 7. The most important factor, however, is how dedicated you are togood oral hygieneat home. endstream endobj startxref Each are available in English and Spanish and available as PDFs for download. Patients with or without insurance need to be informed of what procedures they will be undergoing, what and how often the perio maintenance therapy will be performed, and what the fees will be. I understand that periodontal disease is an infection process that may lead to the destruction of gum tissue, bone supporting my teeth, and that the teeth may be seriously damaged or lost if treatment is not rendered. Scaling and root planing has been recommended to clear away the toxins Each table below corresponds to a category of the clinical note templates. /FontName /Arial,Bold I have been given a chance to ask any questions associated with not treating this disease. /StructParents 0 Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page. /ID [] Code D4910 usually will not be paid unless performed at least three months following active therapy (i.e., either periodontal surgery or D4341, Periodontal Scaling and Root-Planing. endobj Patient refusal to SRP, SCRP, Dental Consent forms, Periodontal Maintenance forms, Understanding dental treatment, Patients guide to dental treatment, dental templates. I request and authorize medical/dental services for me, including implants and other surgery. This dental procedure, with the code D4910, is an ongoing, therapeutic professional teeth cleaning performed on a consistent schedule after the completion of active periodontal treatment. (Parameters of Care 2000 may be obtained from the AAP Web site, www.perio.org.) 0000003910 00000 n /StemV 40 Decide on what kind of signature to create. /S 83 333 500 500 278 278 500 278 778 500 500 500 500 333 389 278 500 500 722 500 Answers to members top questions about physical distancing, patient screening, the use of face coverings, and other COVID-19 prevention requirements. Use this table to determine how long to keep business records such as payroll and employee records, patient records, EOB's and more. Maintaining regular periodontal cleanings is essential. General consent is limited to a discussion regarding the performance of certain procedures that you're recommending for that particular patient. @ ;Q@7m3cn; L*N7:vcYR79=s=wyUQ"u9wBu;>q"Gkm[rleWomX;D%->9+"T'. Mwde':3P=cN'J1hwj^3l1@Qh6$"smiCKHeobtSCuE{%@ J75EQ~A^F^eE? |?#zA_Ne>c0P6}Bktf4NT\4tOZ4~X mbi&=FYTGCvk&z-]h"MYT}}MvD4=t7_Q#x*2w\vst]Gh=BO:a Z@k\9"G~q0`~}ZME1+FE(iz>`l$nhE^mIg1I6RL~&zb|i=K9,ZGjK2#dgb-7EH9a >h} m |xI|jdn.| _FD=G{,YKdI}Gronr26m}DI6-Ikam#>d]) -Jw ,ilHUI7_ZhB-vG=faV|Ubu-=*'8D>o_"^xD]|OB~]37/. This is a written form that gives authorization, by the patient, to allow their dentist to proceed with treatment. /FontDescriptor 30 0 R 1201 K Street, 14th Floor /FontWeight 700 The dates of active therapy should be included on the claim form. . Following a course of non-surgical debridement, the condition would need to be reassessed by carrying out a 6PPC (full mouth measurements) and thereafter further treatment planned. /FontName /Times#20New#20Roman,Bold /CropBox [ 0 0 612 792 ] 24 0 obj Agreed tx plan: HYGIENIST - PERIODONTAL TREATMENT Pt referred by X for non-surgical periodontal therapy 1601 E McAndrews Rd Suite BMedford, OR 97504. All rights reserved. Periodontal maintenance aims to spend time cleaning in and around these areas to regularly maintain stable bone and gum tissue. 36 0 obj It helps if perio maintenance is set up in a routine appointment format with all members of the staff "on the same page" regarding what the appointment will include. /FontBBox [ -558 -216 2000 677 ] /FirstChar 32 /FontWeight 700 Periodontal maintenance (following active therapy) is considered to be an integral part of effective perio treatment. x\{ohl1\$R)(N'J:;*i3O"E}7s/_|IUu_3I2Y^IEr[W|Cr}Z$1Wrayfyk{M|:I30j"IX$|.j]L03n7q}ZE.A== =99eI,iT?$0^cw &xV1{DH.6WwG]U;Gy`cQru2a;d H|q". << NEW PATIENT ASSESSMENTCO & HPC:Perio Bleeding/Loose teeth/Halitosis/Bad taste/Difficulty eating/Sensitivity/Pain/Swelling/Gum boils/Aesthetics/Anything else. /FontDescriptor 24 0 R Patient complaints to state dental boards concerning differences between perio maintenance and standard prophys are on the rise. CDA Foundation. Informed Consent for Periodontal Maintenance Purpose of periodontal maintenance: To prevent the progression and recurrence of periodontal disease. Special investigations:Radiographs: Are these available from the referring dentist? That is, every 24 hours or more frequently, all parts of the tooth accessible to bacteria must be cleaned completely. /Tabs /S Other side effects of treatment include pain, soreness, bleeding, swelling, bruising. 3. 0000002178 00000 n /O 156 Pt referred by X for non-surgical periodontal therapyConsent form and estimate signed? >> 0000004524 00000 n By signing this form, I am freely giving my consent to allow and authorize Dr. David Peterson and/or his associates to render any treatment necessary or advisable to my dental conditions, including While the D0120 may be appropriately reported, it usually will not be covered by insurance. COVID-19 Mask, Screening and Physical Distancing FAQ, Payment Dispute Resolution Forms and Processes, Delta Dental: On-site Quality Assessment Review Checklist, Legal Reference Guide for California Dentists - Appendix D, Legal Reference Guide for California Dentists - Chapter 1, Introduction, Minimum Wage and Paid Sick Leave Ordinances by City/County, Legal Reference Guide for California Dentists - Appendix C: Formation of a Group Practice Checklist, Records and Documents Retention Guidelines, Regulations on Dentists Initiating and Administering Vaccines, California Department of Managed Health Care Licensed Dental Plans, COVID-19 Vaccine Information and Communication Resources, 3 Important Reasons For Adults to Get Vaccinated, Continuing Education Requirements and FAQ, California Department of Managed Healthcare - Information on Provider Complaints, Air Tank and Compressor Inspection and Permit, Certification of Health Care Provider - Employees or Family Members Serious Health Condition, Informed Consent Forms Traditional Chinese. /XHeight 250 This toolkit covers hiring, paying and terminating temporary employees. /FontWeight 700 Smoking? Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com. Please don't hesitate to contact us or . 0000002671 00000 n The way to fill out the All on four consent form on the web: To start the form, utilize the Fill camp; Sign Online button or tick the preview image of the blank. REQUEST APPOINTMENT. Sacramento, CA 95814 Periodontal Information Leaflet & Consent Form Some of the signs of periodontitis are: Periodontal treatment Bleeding gums Healthy Gums DO NOT Bleed Swollen and tender gums . A typical maintenance visit for patients with dental implants should last 1 hour and should be scheduled every 3 months to evaluate any changes in their oral and general history. A dentist who prescribes and administers any vaccine must follow requirements for training, continuing education, notifications, reportingand documentation established in Section 1066 of Title 16 of the California Code of Regulations. This is a summary and FAQ of the Dental Boards continuing education regulations. Explained referral to specialist might become appropriate. <> Info on practice management audits: practice strategic plan, production goals and revisions to schedule, chart audit, financial audit, billing, and how to update management policies and procedures. Periodontal Disease is an infection of the gums and bone which if left untreated, will eventually destroy the support for your natural teeth. /ItalicAngle 0 0000003716 00000 n I consent to photography, filming, recording, and xrays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed without my further permission. The information given to the patient in these circum- When patients understand what treatment they will be receiving, they are much less likely to complain later to your office or the state dental board. /Length1 10836 If you want to reduce your risk of labor litigation, its important you understand Californias meal and rest break requirements. (home care) on a daily basis and periodic periodontal maintenance visits at a dental office after the proposed surgical treatment performed. For practical purposes, the perio-maintenance appointment might follow a consistent format utilizing four effective chart forms or computer screens. The AAP describes periodontal maintenance as the treatment provided to individuals after the completion of initial (nonsurgical) periodontal therapy with the intention of preventing further disease progression and maintaining the health of the periodontium. Choose My Signature. << | Site last updated: 24 January 2023| Made by Digimax Dental Marketing. However, insurance carriers are expected to continue to use "case types" for the near future.). /FontBBox [ -558 -216 2000 677 ] Medical condition? % The primary cause of gum disease dental plaque accumulation especially in genetically susceptible people. /Type /FontDescriptor It is essential . /CIDSystemInfo 35 0 R /Linearized 1 /T 85791 Emphasised that during treatment the gums may shrink back due to recession and so the teeth can look longer with gaps in between teeth/black triangles. The following are items to include in a dental consent form:. Untreated perio and COVID-19: What is the evidence? /Length 135 /FirstChar 32 500 500 500 500 0 278 278 0 0 0 0 0 722 0 0 722 0 556 722 722 333 0 0 0 889 endobj These would be: An updatable medical and dental history form A dental examination form A periodontal form that documents probing, bleeding, furcations, recession, and mobility. /FirstChar 32 800.232.7645, About California Dental Association (CDA). Products . %=)`t0D4KL" o (YbJX,0U$i@ZIJAt1])ba3lEgNH\?hM~1[h. Obtaining general consent means that the patient has given you permission to proceed with treatment and released . /StemV 47 California Dental Association /Encoding /WinAnsiEncoding /Subtype /CIDFontType2 /CapHeight 677 TREATMENT PROCEDURES * Oral hygiene/disease prevention . /FontFile2 37 0 R Updated January 03, 2023. /Group << /Type /Group /S /Transparency /CS /DeviceRGB >> Checklist of the items that should be addressed or considered when forming a group dental practice. Unless you have customized your clinical note templates, your database should include these default templates. /Descent -216 2023 Reena Wadia. hTmk0+~ F m%~Z_Hx/[XdI` cp983ppct9ppgB nnHRuR0("i]icsUKtYS/3dv\"!IU+`.-L3+Ve %%EOF 21 0 obj 0000003940 00000 n /Filter /FlateDecode >> endobj Term and termination; liability; referrals; utilization review; grievance system. The proposed treatment plan to arrest the effects of periodontal disease that has been explained to me and I understand that additional treatment may be needed later if further problems develop. 0000004139 00000 n Richins, Weinstein and Boyapati have completed the active phase of periodontal treatment, your periodontal disease will be under control. Early detection and aggressive treatment are critical to stopping or slowing the progression of the disease to the point of tooth loss. 27 0 obj <>stream /Type /FontDescriptor Follow. /AvgWidth 479 A periodontal form that documents probing, bleeding, furcations, recession, and mobility. I understand that additional treatment may be needed if problems occur in the future. These include, among others, an update of medical and dental histories, radiographic review, soft-tissue exam, dental exam, perio exam, plaque-control effectiveness, removal of subgingival and supragingival plaque and calculus, removal of microbes from pocket areas, and tooth-polishing. >> Plaque is soft and sticky, and is continually forming. appliances; periodontal maintenance procedures. endstream Scaling removes tartar and bacteria from your tooth surfaces and below your gumline. 278 833 556 500 556 0 444 389 333 556 500 0 500 500 ] Insurers usually pay for two "exams" of any type per year and include a D0120 under that heading. << /BaseFont /Times#20New#20Roman,Bold Insurers usually will not pay for a D0120 charged out on the same day as a D4910. x[K, _@U.4 d7,2@2-[};$$\n*?dIR]~O93vx3U>a?|B -Xp.'kq2(v)J{o&VP)}qr{k'wyguW?-4swiO%]DV&W^5jUm&D^^ www%=JuTdjrRGq7zp};I"/~!3la;4Zf:=3eSI[-SNb=d(_VdJx..#nCZk~AuZ> 6c 6|lq\&-e.\pLYL?q{$0yeW&(^ >`TiHPm;0;!$HUNd:mMx,u."[_b7qXw?6zv}W}imwv]d] a week)Occupation Stress levels , DH:Toothbrushing- Brushes /day with a F- toothpaste for mins (manual/electric)Interdental cleaning-Mouthwash-Diet- sugar, acidParafunctional or Other habits-Dental anxieties-, EO:TMJ & muscles of mastication NADLips NADSymmetry NADScars NAD, IO-Soft tissues:Labial mucosa NADBuccal mucosa NADFOM NADTongue NADHard & soft palate- NADOropharyngeal region- NAD, Gingivae BPE- Completed?Oral hygiene- good/fair/poor, plaque-, calculus-, Periodontal examination 6PPC completed . /Type /Catalog Consistency in coding and documentation for both recordkeeping and insurance claims can reduce billing and payment problems. /Leading 33 Informed consent and patient records Where reasonably foreseeable risks, potential complications, or the possibility of failure are associated with treatment, informed consent should be obtained prior to the commencement of therapy. %%EOF [ 250 0 0 0 0 833 778 0 333 333 500 0 250 333 250 278 500 500 500 500 500 /LastChar 121 %PDF-1.5 31 0 obj 1 When incorporated into a routine oral maintenance program along with scaling and root planing (SRP), results were achieved after 1 month, with pocket depth reduction seen at 3 months and maintained at 9 months.1 . Treat your patients beyond the office. Since the CDT-3 description of Code D4910 does not include a periodic evaluation, then a D0120-Periodic Oral Evaluation may be properly reported as a separate fee, as would any code or fee for radiographs. Gloves Off: Can a nightguard kill a sleep apnea patient? After filing a provider dispute/complaint/appeal with a dental plan, learn how to file a 2nd level provider complaint with the California Department of Managed Healthcare. xc```b`` e`e``d@ A+* @e>Q4@U!q(f`f`fXQaWFo=kEMTTV\H], ?! /FontDescriptor 36 0 R There are at least three good tools for cleaning between the teeth, where most periodontal disease begins. . A few carriers downcode payment to what they allow for a D1110-Prophylaxis-Adult. It also helps if patients are given detailed explanations along with written informed consent forms and fee estimates prior to the surgery or root-planing requiring the supportive therapy. )5xyP+%*~xld@f4bs@w|mb5uiZdPKB(y&&Sm.x.#p3~|NdNpFh@QWM#U YWH:@f4FIZP Part 2 of 3. << Diabetes advice? Lets get progressive! >> Use this list to compare aspects of a QA review with your practice's policies and procedures, and be even better prepared for a future on-site QA review. 20 0 obj Code D4910 is an important and usually adequately-paid code describing periodontal maintenance. << >> /XHeight 250 Washington. endobj /StemV 42 as well as periodic periodontal maintenance therapy after the proposed treatment at a dental office. /FontWeight 400 endobj /Type /Font The colonies cause irritation and inflammation, which create an . They will then provide you with a personalized maintenance program of care to keep your gums healthy. /CapHeight 693 During your maintenance cleaning, the hygienist will evaluate and record your periodontal pocket depths and check for hidden periodontal problems. /W 38 0 R << /Length 5 0 R /Filter /FlateDecode >> This consent form lists various treatments. endobj Assists with drafting specific break policies for your practice that are compliantwith California laws. Early recognition and prevention of the disease recurrence. % 1 0 obj Consent for Periodontal Treatment PATIENT NAME: _____ DOB:_____ Today's Date: _____ . If untreated, it leads to the loss of teeth. Don't worry if you are prescribed periodontal maintenance. 25 0 obj 45 0 obj /CIDToGIDMap /Identity D4341 periodontal scaling and root planing Four or more teeth per quadrant D4342 periodontal scaling and root planing One to three teeth per quadrant Create Document. Short-term employees are considered employees by the State of California and require additional documentation. It requires the signature of the patient, and it should be a comprehensive form that covers risks, benefits, alternatives, and medical issues. Browse the forms in five different categories: Consent Forms Denture Treatment Endodontic Treatment Endodontic Treatment 2 Endodontic Treatment 3 - English Endodontic Treatment 3 - Spanish Extraction of Teeth 1 Extraction of Teeth 2 Extraction of Teeth 3 Extraction of Teeth - Spanish General Consent General Consent - Spanish Treatment of periodontal disease includes scaling and root planing, effective home care, possible referral to a periodontist (gum specialist), and possible surgery. 26 0 obj /Widths 28 0 R [ 250 0 0 0 0 0 0 0 0 0 0 0 250 333 250 0 0 500 500 500 500 500 0 0 0 0 333 Periodontics Perio Therapy (FMD, SRP, perio maintenance) Consent Form Crown Lengthening Consent Form Crown Consent Form (Prosthetic Crowns) Radiology Declining X-rays Consent Form Orthodontics Prosthodontics Miscellaneous High Risk Nerve Injury Consent Form Broken Appointments Consent Form Discount Treatment Consent Form Office Hours Monday Closed %PDF-1.4 /AvgWidth 427 stream endobj << KTVX! This non-surgical deep cleaning removes tartar, plaque (biofilm), and bacteria from the tooth at and below the gumline and its roots. The advanced tools of the editor will lead you through the editable PDF template. Use our Consent Forms in Spanish. Alternating codes between D1110 and D4910 is not reasonable; however, some insurance carriers encourage and/or accept it. /Encoding /WinAnsiEncoding Spanish Dental Office Forms. /Filter /FlateDecode /FontName /ASJHEV+Times#20New#20Roman,Bold The action you just performed triggered the security solution. It also promotes your gum tissue's regeneration to grow back snug around your tooth. 0000000989 00000 n Part 3 of 3, Untreated periodontitis and COVID-19: What is the evidence? << /MarkInfo << /Marked true >> CDC Guidance for Donning and Doffing Personal Protective Equipment (PPE). /Encoding /WinAnsiEncoding hb```e``` 9oT, bPX;TSX# ` yjqyxO/xzej.]C{}|}U_6$kl#OAmu*kUl[4-rVtAkq..]xgZsU=wv _P]mt[pnrki%_16l}6s9e]g8O.>dev- /Ordering (Identity) endobj Encourage vaccination with this flyer from the CDC. %PDF-1.3 *Maintenance similar to above but likely to check probing depths and carry out maintenance scale*OTHER KEY PHRASESPatient advised of mild/moderate/severe periodontal diseasePatient warned of tooth mobility and tooth loss related to periodontal diseasePatient advised that they are at risk of developing periodontitisPatient advised of smoking related to periodontal disease increase risk factor for condition and poorer response to therapyPatient advised that oral hygiene is not adequate to support formal periodontal therapy. INFORMED CONSENT I have been informed I have periodontal disease. /Size 46 37 0 obj /ExtGState << /GS7 40 0 R /GS8 41 0 R >> /XObject << /X0 43 0 R >> >> Explained may need more than one course of non-surgical debridement. 6101 Grace Park Dr Morrisville, North Carolina 27560 Telephone: (919) 493-9900 Fax: (919) 493-9901. Review Us on Google A dental consent form is a written authorization signed by a patient that gives a dentist the go-ahead to perform specific procedures. A periodontal evaluation may imply a periodontal diagnosis or it may be considered as only one component of a total evaluation prior to a diagnosis. As a member service, CDA has compiled a list of dental plans from the Department of managed Health Care website. There are two levels for appealing payment disputes: first with the plan itself, then with the appropriate regulatory agency. Emphasised importance of excellent oral hygiene and maintenance to help achieve optimal treatment results. /MaxWidth 2628 Individual cities and counties across California have passed local ordinances relating to minimum wage and sick leave laws with eligibility rules varying from city to city. <>>> 35 0 obj As a member of the National Society of Dental Practitioners and a Dentist's Advantage client, you have access to a library of dental consent and record keeping forms. endobj I have refused to undergo periodontal treatment. Another staff member or the dentist can provide this information at the same time that all of the patient's treatment is being discussed. Informed Consent - Periodontal Treatment Patient Name _____ Procedure _____ I understand that I have periodontal (gum and bone) disease. /Flags 32 At the maintenance visit my bridgework, implants and gums will be checked and measurements, photographs and x-rays may be The ADA defines periodontal maintenance procedures as "D4910-Periodontal Maintenance Procedures (following active therapy) This procedure is for patients who have completed periodontal treatment (surgical and/or non-surgical periodontal therapies exclusive of D4355) and includes removal of bacterial flora from crevicular and pocket areas, scaling and polishing of the teeth, periodontal evaluation, and a review of the patient's plaque control efficiency. An updatable medical and dental history form. /Ascent 891 qE[T[-v*F XEFq m# (N`7B^bUGBJS Dentrix Ascend includes a collection of default clinical note templates. The disease process has been explained to me and I understand that it is caused by bacterial toxins (poisons . /Ascent 905 PATIENT CONSENT I have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks and benefits of periodontal surgery, the alternative treatments available, and the necessity for follow-up and self-care. /ToUnicode 39 0 R Complete progressive periodontal probing depths, bleeding points, recession, furcations, and mobility. hbbd``b` ]$8 V a&H #1? 33 0 obj It should be; Voluntary: The person either the parent or guardian giving consent hasn't been put under pressure. endobj Periodontal maintenance requires patients to visit the dentist more frequently than traditional visits which occur every 6 months. Sacramento, CA 95814 I fully understand /MaxWidth 2558 Explained that during the cleaning process, there is always a chance of damaging/loosening/decementing any restorations/veneers/crowns/bridges. Once stable, emphasised the importance of life-long regular (to be defined according to risk but initially 3 monthly) maintenance appointments to ensure periodontal condition remains stable/pick up any relapse and treat as early as possible. xYyxTU?*K%%UR! An Important Message from Santa Teresa Dental Regarding COVID-19. 30 0 obj Periodontal disease and tooth decay are the two biggest threats to dental health. /AvgWidth 427 0000001707 00000 n There are three variants; a typed, drawn or uploaded signature. /Descent -210 /Subtype /TrueType There are a number of treatment options depending on the . All you need to know about dental treatment consent forms. The consequences of doing nothing or discontinuing treatment may be, but are not limited to: Worsening of the disease causing increased bone loss which may lead to the need for teeth to be extracted in the future.