Informed Consent Form: Scaling and Polishing
Dentist’s Name:
Benefits and Alternative Treatments:
- Prevent gum disease
- Eliminate mouth odors
- Cleaner looking teeth
Some portions of the procedure may be performed by auxiliary personnel.
Alternatives: None
Common Risks:
- Sensitive teeth
- Feelings of spaces between teeth
- Loosening of fillings (normal if filling was ready to fall out)
- Sensitive gums
Consequences of Not Performing Treatment:
- Gum disease
- Increased risk of tooth loss
- Tooth decay
- Staining on teeth
Every reasonable effort will be made to ensure that your condition is treated properly, although it is not possible to guarantee perfect results. By signing below, you acknowledge that you have received adequate information about the proposed treatment, that you understand this information, and that all of your questions have been answered fully.
"I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".
I give my consent for the proposed treatment as describedabove.
I refuse to give my consent for the proposed treatment as described above. I have been informed of the potential consequences of my decision to refusetreatment.
