Laser Periodontal Therapy Form

Informed Consent and Authorization for Treatment

• I understand that dental lasers marketed and sold in the United States have been cleared by the Food and Drug Administration (FDA) for use in dentistry. I have been presented with the laser treatment plan and fees for treatment. The expected results and risks of the proposed treatment and treatment have been explained to me.
• I understand there is no guarantee of success or permanence of treatment.
• I understand professional efforts will not work alone. My commitment is needed to ensure the success of this program. This depends on me coming in for office therapy and doing home care recommendation every day to remove the bacteria at home.
• I understand that initially it will be necessary to come in for a supportive periodontal maintenance visit every 3 months with the hygienist.
• I understand that dental conditions in my mouth can change and alter the proposed treatment plan.
• I understand that anytime that soft tissue is manipulated, whether by traditional dental technology or laser dentistry, there is always a possibility and risk of unexpected and undesirable side effects.
• I understand that high-technology dentistry including laser therapy, will not be reimbursed by insurance companies and I must anticipate paying 100% of any such treatment. I understand this office does not operate on the assumption that insurance will reimburse me for the treatment rendered.
• I understand that this office is performing this treatment in my own best interest.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

I have read and agreed to the foregoing. I have had the opportunity to ask treatment related questions and have been advised of the risks and benefits of treatment. I understand that it is necessary to complete all phases of recommended treatment, and agree to do so.

I authorize the performance of dental treatment using dental lasers.

I understand that I have periodontal disease, for which a routine cleaning will not benefit my health. In fact, failure to treat the disease may result in the eventual loss of my teeth and in some instance, acute illnesses such as heart attack and stroke. But I decline treatment for now.