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TREATMENT REFUSAL FORMS These forms are ... - Dental XP

TREATMENT REFUSAL FORMST hese FORMS are intended to be used when a patient refuses the TREATMENT . These FORMS help confirmthat the patient is informed and aware of the risks involved with not proceeding with recommendedtreatment. Form A(Doctor Name), DDS (DOCTOR'S ADDRESS)DISCUSSION AND REFUSAL OF TREATMENTD iagnostic Radiographs (X-Rays)Patient s Name _____ I am being provided this information and REFUSAL form so I may fully understand the procedurerecommended for me and the consequences of my REFUSAL . I wish to be provided with enoughinformation to make a well-informed decision regarding the proposed has been recommended that I have routine diagnostic radiographs based on the AmericanDental Associations guidelines (a full mouth series every 3-5 years and bitewings every 1-2 years).

Dental Associations guidelines (a full mouth series every 3-5 years and bitewings every 1-2 years). I understand that the radiographs are necessary for my dentist to diagnose and treat possible decay (cavities), infection, fractured teeth, bone loss due to gum disease, and tumors. Without periodic

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Transcription of TREATMENT REFUSAL FORMS These forms are ... - Dental XP

1 TREATMENT REFUSAL FORMST hese FORMS are intended to be used when a patient refuses the TREATMENT . These FORMS help confirmthat the patient is informed and aware of the risks involved with not proceeding with recommendedtreatment. Form A(Doctor Name), DDS (DOCTOR'S ADDRESS)DISCUSSION AND REFUSAL OF TREATMENTD iagnostic Radiographs (X-Rays)Patient s Name _____ I am being provided this information and REFUSAL form so I may fully understand the procedurerecommended for me and the consequences of my REFUSAL . I wish to be provided with enoughinformation to make a well-informed decision regarding the proposed has been recommended that I have routine diagnostic radiographs based on the AmericanDental Associations guidelines (a full mouth series every 3-5 years and bitewings every 1-2 years).

2 Iunderstand that the radiographs are necessary for my dentist to diagnose and treat possible decay(cavities), infection, fractured teeth, bone loss due to gum disease, and tumors. Without periodicradiographs, my dentist cannot identify and disclose to me potential problems, which could lead toserious jaw infections, tooth loss, and bone destruction leading to potential jaw fractures. No other reasonable option to Dental radiographs exists at this time. I am informed that thedose of radiation is minimal from such Dental radiographs, and that all necessary precautions will betaken to ensure exposure is minimal (lead apron, collar and digital imaging).

3 _____ I have had an opportunity to ask questions about Dental radiographs, risks of x-ray exposure, andrisks associated with not taking have received the above information about the proposed radiographs. I have discussed mytreatment with Dr. _____ and have been given the opportunity to ask questions and have them fullyanswered. Dr. _____ has informed me of the need for Dental radiographs, risks associated with nottaking radiographs, and my REFUSAL to take radiographs. I also understand that Dr. _____ will refuseto treat me if I refuse necessary diagnostic : _____ Date: _____Patient or GuardianSigned: _____ Date: _____Treating DentistSigned: _____ Date: _____WitnessForm BYOUR OFFICE HEADERD iscussion and REFUSAL of TreatmentPatient s Name: _____Risks of Not Having the Recommended TreatmentI understand that complications to my teeth, mouth, and/or general health may occur if I do notproceed with the recommended TREATMENT .

4 These complications include: _____ I have had an opportunity to ask questions about These risks and any other risks I have heard or thought , _____, have received information about the proposed have discussed my TREATMENT with Dr. _____ and have been given anopportunity to ask questions and have them fully answered. I understand the nature of therecommended TREATMENT , alternate TREATMENT options, and the risks of the recommended TREATMENT , andmy REFUSAL of personally assume the risks and consequences of my REFUSAL , and release for myself, my heirs,executors, administrators, or personal representatives those dentists who have been consulted in mycase from any and all liability for ill effects which may result from my REFUSAL to consent to theperformance of the proposed acknowledge that I have read this document in its entirety.

5 That I fully understand it and that allblank spaces have been completed or crossed off prior to my do NOT wish to proceed with the recommended : _____ Date: _____Patient or GuardianSigned: _____ Date: _____Treating DentistSigned: _____ Date: _____WitnessForm CYOUR OFFICE HEADERD iscussion and REFUSAL of TreatmentPatient s Name:_____ Date of Birth: _____LastFirstInitialI am being provided this information and REFUSAL form so I may fully understand the treatmentrecommended for me and the consequences of my REFUSAL . I wish to be provided with enoughinformation, in a way I can understand, to make a well informed decision regarding my understand that I may ask any questions I wish regarding the recommended of the Recommended TreatmentIt has been recommended that I have the following TREATMENT : _____This recommendation is based on visual examination(s), on any x-rays, models, photos and otherdiagnostic tests taken, and on my doctor s knowledge of my medical and Dental history.

6 The TREATMENT isnecessary because of: Decay Broken Tooth/Teeth Infection Periodontal (Gum) Disease Pain Other _____The intended benefit of this TREATMENT is: _____The prognosis, or chance of success, of this TREATMENT is: _____My TREATMENT is estimated to take _____ visits to TREATMENT is estimated to cost $ TreatmentsThe TREATMENT recommended for me was chosen because it is believed to best suit my understand that alternative ways to treat my Dental condition include _____ No other reasonable TREATMENT option exists for my I have had an opportunity to ask questions about These alternatives and any other treatments I have heard or thought about.

7 Including _____Risks of the Recommended TREATMENT I understand that no Dental TREATMENT is completely risk free and that my dentist will takereasonable steps to limit any complications of my TREATMENT . I understand that some after-treatmenteffects and complications tend to occur with regularity. These include_____ LASER ASSISTED NEW ATTACHMENT PROCEDURE INFORMED CONSENTI consent to _____, DDS performing LANAP (Laser Assisted New Attachment Procedure)therapy on BENEFITS OF LANAPLANAP therapy is designed to eliminate or substantially reduce periodontally diseasedgums and/or pockets to help control or prevent future periodontal disease reduces periodontal gum pocket depth by facilitating:A) Improved visualization of the laser detached gum pocket soft tissue linings to aidscaling and root planing for removal of tartar (calculus).

8 B)Re-attachment of the laser treated gum tissues to the roots by promoting growth ofnew bone and/or root surfaces. LANAP treatments are generally less painful thanflap surgical procedures. LANAP peer reviewed research proves predictable re-attachment of gum tissue and bone growth to promote long term periodontal healthand to preserve ALTERNATIVE THERAPIESDr. _____ has explained to me alternatives, benefits, and potential complications oftreatments for my periodontal disease as follows:A) Non-surgical root planingAfter local anesthetic injections of my gums, root surfaces are scaled and deepcleaned (planed) to the bottom of any gum pockets by hand or ultrasonicinstruments to remove bacterial plaque on teeth and root tartar (calculus) )Periodontal flap surgeryAfter local anesthesia injections, flap surgery involves surgically incising my gumtissues.

9 After the gums are flapped and surgically lifted away from my teeth,underlying diseased gum tissue is curetted out, roots planed, diseased bonetrimmed and/or grafted. Finally the flap of gum tissue is closed with sutures. C) ComplicationsNon-surgical scaling and root planing alone may not eliminate or substantiallyreduce deep pockets. LANAP may be done for further periodontal pocket depthreduction if root planing does not shrink deep gum pockets. Periodontal surgerytreatment risks include post-operative bleeding, infection, swelling, sinusitis and insurgeries close to facial nerves on rare occasions numbness and/or pain of the lip,chin and gums.

10 III. LANAP COMPLICATIONSLANAP post-surgical complications, if any, are usually milder, less severe and not as longlasting as conventional periodontal flap surgery LANAP- NO GUARANTEELANAP, as with all periodontal procedures, may not be entirely successful in gum pocketreduction or new attachment. Success is not guaranteed. Nonetheless, other LANAP performing dentists report that almost 90% of LANAP treated patients required noLANAP re- TREATMENT during the first 5 years after LANAP therapy. RISKSD oing nothing can worsen my periodontal disease including increased gum pocket depthwhich predisposes to early (premature) teeth loss, infections, and abscesses.


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