Periodontal Treatment Consent Form

Dental Treatment Proposed
Name of patient who will receive treatment proposed.*
First Last
Date of Birth*
DD slash MM slash YYYY
Please confirm your explicit consent to receiving treatment:*
I confirm that I have read through the treatment guide and understand the benefits, risks, and limitations of treatment. I have had the opportunity to ask relevant questions about the treatment. While providing consent to commence treatment, I understand that I may withdraw consent to continue treatment at any time by providing my instructions in writing.
- I consent to the proposed treatment.
Name of person providing consent*
First Last
I confirm that I am :*
- The patient
- Parent or Legal Guardian of the patient
- The patient's representative
Email*
Signature*
Date*
DD slash MM slash YYYY

Antwerp Implant Dentistry will thoroughly treat your gum disease before commencing implant therapy !