Consent Form

You information is safe! The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

A. For Appointment Policy:

We know your time is important and so is ours. We make every effort to confirm patient appointments, but we give appointment cards so you will have a record of your date and time. It is your responsibility to keep this information. We also make every effort to be on time and expect that you will too. If you are more than 10 minutes late, it may not be possible for us to thoroughly complete the task and you may need to be rescheduled. This time is reserved especially for you. Any change in this appointment affects many people. Thank you for your understanding.

B. For Exam and Data Collection:

This is my Consent for Dr. Lynn Sayre-Carstairs and/or her assistants or hygienists to perform the procedures deemed advisable and necessary to evaluate my periodontal condition. The procedures may include but are not limited to a full periodontal examination (probing), X-rays (radiographs), and bacterial sampling. I understand that all treatment deemed necessary will be discussed with me by Dr. Sayre-Carstairs prior to execution and I will have the opportunity to ask any questions regarding my evaluation at any time.

C. For Treatment – Cleaning of Teeth and Gums

This is my consent for Dr. Sayre-Carstairs and/or her hygienists to clean my teeth. I understand that there are possible side effects to this care and they vary depending on the procedure to be completed ie: Non Surgical Hygiene Therapy, Deep Cleaning (scaling/root planning) and use of a Dental Laser in conjunction with treatments. The side effects include, but are not limited to, tooth/root sensitivity or mobility. There may be recession of the gums. Existing dental work may become damaged. The nerve of the tooth may flare up requiring a root canal later on. The muscles of the face or neck may spasm and require further evaluation and/or treatment. If anesthesia is to be used, swelling, bruising and prolonged numbness may result. Infection of any area of the mouth is a possibility. All treatments will be discussed with me prior to execution and I will have the opportunity to discuss my care with Dr. Sayre-Carstairs and/or her staff at any time.

D. For Surgical Treatment:

This is my consent for Dr. Sayre-Carstairs to perform periodontal surgery which I have agreed is necessary for my oral health. I have had the opportunity to discuss options and alternative treatments. All my questions have been answered in a way that I understand. Side effects of periodontal surgery include but are not limited to infection, swelling, bleeding, bruising and recession of the gums. There may be post-operative prolonged numbness. Tooth and gum sensitivity may occur along with tooth mobility. Damage to existing dental work or the nerve may occur which may require further care. Muscle fatigue or spasm is a possibility. I have been informed that if I am to take oral sedation, a driver is required to take me from my appointment. I am not to operate a motor vehicle or heavy equipment for 24 hours.