Diagnosis: After careful oral and radiographic examination, my periodontist has advised me that I have a form of periodontal disease or a periodontal condition that has caused damage to the soft tissues and/or bone around my teeth. This condition, if left untreated, is generally non-reversible and can be progressive, eventually leading to further damage and possible loss of teeth.

Recommended treatment: The purpose of this procedure is to gain access to the tooth and bone surfaces affected by periodontal disease. The gum tissue is retracted back allowing the periodontist to access the teeth and bone. The root surfaces will be thoroughly cleaned, and the bone may need to be reshaped, sutures may be required. 

I understand that local anaesthetic will be administered to me as part of the treatment and I have the option of sedation.

I have been informed and I understand the purpose of periodontal surgery (pocket depth reduction/flap debridement) procedure. Expected benefits: Eliminating or decreasing pocket depths will enable better access for you and dental professionals to adequately maintain gum health.

Primary risks and complications: I understand there can be complications of the Periodontal surgery, drugs and anaesthesia including, but not limited to:

I understand that complications may result from the surgery, drugs, and anaesthetics. These complications may include but are not limited to:

• Pain, swelling and post-operative discolouration of the face, neck and mouth

• Bleeding which might require more advanced techniques to control

• Post surgical infection

• Transient or permanent numbness of the lip, tongue, teeth, chin or gum

• Restricted ability to open mouthImpact on speech

• Allergic reactions

• Injury to teeth

• Limitation of jaw function and stiffness of jaw and facial muscles

• Referred pain to the ear, neck or head

• Post-operative, unfavorable reactions to drugs, such as nausea, vomiting and allergies

• Shrinkage of the gum upon healing which may result in increased sensitivity due to the exposure of the root

• Accidental swallowing of foreign objects

• Delayed healing
  

I understand that if I smoke I have an increased risk of the above complications. The exact duration of any complication(s) can not be determined, and they may be irreversible.

Alternatives to suggested treatment: I understand that alternatives to periodontal surgerymay include: 1) no treatment, 2) continue with maintenance and debride periodontal pockets as necessary non-surgically 

No warranty or guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful due to individual patient differences; a periodontist cannot predict certainty of success. There exists the risk of failure, relapse, additional treatment, or worsening of my present condition including the possible loss of teeth or implants despite the best care. It has been explained to me that long term success of treatment requires my cooperation and performance of effective plaque control (home care) on a daily basis and periodic periodontal maintenance visits with a dental professional after the proposed surgical treatment has been performed. 

Sedation:  Please speak to your treatment coordinator if this is something you wish to discuss further as this requires to be arranged prior to your procedure date, with a minumum of 24 hours notice.

I understand that if I take oral sedation, I will need a driver to and from my appointment and that I should not operate any heavy equipment/machinery for 24 hours following the use of oral sedation.

Payment Terms: I understand the proposed treatment plan estimation which has been presented to me as a written treatment plan outlining the required appointments, time frames, item codes and the fees associated with my treatment. 

I understand all appointments are to be paid in full on the day of the procedure, and I will be mindful of any daily bank card limits I may have, thus ensuring full payment can be made. 

I understand that if I wish to make payment via direct deposit that I will contact my treatment coordinator at least two days prior to my appointment, ensuring the funds have cleared before the commencement of my appointment. 

I am aware that a HICAPS terminal is not available on site and I will claim any benefits that I may be entitled to directly from my health fund.

Patient Consent: I have been fully informed of the nature of t he periodontal surgery the risks and benefits, the alternative treatments available and the necessity for follow up care. I have had an opportunity to ask any questions I may have in connection with the treatment and discuss my concerns with my periodontist. I hereby consent to the periodontal surgery as presented to me during consultation and in the treatment plan. I understand that during the procedure, conditions may become apparent which warrant additional or alternative treatment for my best interest, which I will be informed of. This may involve additional costs that may not have been outlined in the provided treatment plan.

I Understand the success of surgical procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, adequate oral hygiene, and medications that I may be taking. To my knowledge I have reported to my periodontist any prior drug reactions, allergies, diseases, symptoms, habits or conditions that in any way relate to this surgical procedure.

I have agreed to follow the post-operative instructions and to report to all follow up appointments.

Please note, due to the sterile environment, no family or friends are permitted chairside at the time of the procedure.

By providing my signature, I certify that I have read and fully understand this document and that all my questions have been answered to my satisfaction.