--- title: Dental Scaling and Root Planing Consent Form Template | Paperform description: Professional consent form template for dental scaling and root planing procedures. Includes treatment necessity, anesthesia options, patient consent, and periodontal maintenance scheduling for dental practices. url: "https://paperform.co/templates/dental-scaling-and-root-planing-consent-form" type: static generatedAt: "2026-04-04T00:43:46.118Z" --- [← Back to free form templates](/templates/) ![Dental Scaling and Root Planing Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-scaling-and-root-planing-consent-form.png) [Preview](https://_preview.paperform.co/ai-template/dental-scaling-and-root-planing-consent-form) [Use this template for free](/create?ai-template=dental-scaling-and-root-planing-consent-form) [Healthcare & Medical Forms](/templates/category/healthcare/)[Legal & Compliance Forms](/templates/category/legal/) [Healthcare](/templates/industry/healthcare/)[Dental](/templates/industry/dental/) [Physician](/templates/role/physician/)[Dentist](/templates/role/dentist/)[Healthcare Administrator](/templates/role/healthcare-admin/) About this free form template ### Professional Scaling and Root Planing Consent Form Template Dental practices providing periodontal treatments need clear, comprehensive consent documentation that protects both the practice and ensures patients fully understand their treatment plan. This **Scaling and Root Planing Consent Form** template is designed specifically for dental clinics, periodontists, and oral health professionals who perform deep cleaning procedures. #### Why dental practices need this form Scaling and root planing (SRP) is a non-surgical periodontal treatment that goes beyond routine cleanings. Because it involves deeper intervention, proper informed consent is essential—not just for legal protection, but to build patient trust and ensure treatment compliance. This form covers everything from treatment rationale and anesthesia options to post-procedure care and follow-up maintenance schedules. #### What makes this template effective Built with Paperform, this template allows your practice to collect detailed patient information, document informed consent, capture digital signatures, and schedule follow-up appointments—all in one seamless experience. Patients can complete the form on their own device in the waiting room or at home before their appointment, reducing paperwork and streamlining your intake process. The form includes conditional logic that adjusts questions based on patient responses, ensuring relevant information is captured without overwhelming patients with unnecessary fields. For example, specific anesthesia preference questions appear based on patient comfort levels and previous experiences. #### Perfect for dental and periodontal practices Whether you're a general dentist offering periodontal services, a specialized periodontist, or part of a multi-location dental group, this template adapts to your workflow. Customize the medical history questions, add your practice branding, adjust consent language to match your protocols, and embed the form directly on your website or patient portal. With Paperform's native integrations, submissions can flow directly into your practice management software, trigger appointment confirmation emails, or update patient records in your CRM. For practices looking to further automate their workflows, **Stepper** can help route completed consent forms to the appropriate staff, trigger insurance verification processes, or schedule automated pre-appointment reminders. #### Secure, compliant patient data handling While Paperform is not HIPAA compliant, it offers SOC 2 Type II compliance and strong security features suitable for many healthcare administrative workflows. For practices requiring HIPAA compliance, consider using this form for general consent and scheduling, while keeping protected health information in your certified systems. #### Streamline periodontal treatment workflows This template helps dental practices reduce administrative burden, improve patient communication, and maintain thorough documentation of consent for periodontal procedures. With **Papersign** integration, you can even turn completed forms into formal treatment agreements that require additional signatures from multiple parties if needed. Get started with this template today and create a smoother, more professional experience for patients undergoing scaling and root planing procedures. Built for growing businesses, trusted by bigger ones. Trusted by 500K+ business owners and creators, and hundreds of millions of respondents. ![Capterra - 4.8 out of 5](/images/capterra-st.jpg) ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg) ![G2 - 4.8 out of 5](/images/g2-st.jpg) [Try Paperform free now](/register) ## More templates like this [![Dental Composite Filling Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-composite-filling-consent-form.png) ### Dental Composite Filling Consent Form A comprehensive consent form for composite (tooth-colored) filling procedures, including amalgam-free restoration options, shade matching, longevity expectations, and patient acknowledgment of treatment risks and benefits.](/templates/dental-composite-filling-consent-form/) [![Dental Gingivectomy Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-gingivectomy-consent-form.png) ### Dental Gingivectomy Consent Form A comprehensive dental consent form for gingivectomy procedures, documenting patient understanding of gum tissue removal, aesthetic goals, periodontal benefits, and informed consent for surgery.](/templates/dental-gingivectomy-consent-form/) [![Dental Implant Surgical Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-implant-surgical-consent-form.png) ### Dental Implant Surgical Consent Form A comprehensive surgical consent form for dental implant procedures, covering procedure risks, bone integration timelines, and multi-phase restoration processes.](/templates/dental-implant-surgical-consent-form/) [![Full Mouth Reconstruction Treatment Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/full-mouth-reconstruction-treatment-consent-form.png) ### Full Mouth Reconstruction Treatment Consent Form A comprehensive consent form for full mouth reconstruction procedures, covering treatment planning, multiple procedure coordination, temporary restorations, financial investment, and patient acknowledgments.](/templates/full-mouth-reconstruction-treatment-consent-form/) [![Oral Surgery Biopsy Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/oral-surgery-biopsy-consent-form.png) ### Oral Surgery Biopsy Consent Form A comprehensive consent form for oral surgery biopsy procedures, covering tissue sample collection, pathology testing, result notification and follow-up treatment planning.](/templates/oral-surgery-biopsy-consent-form/) [![Periodontal Deep Cleaning Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/periodontal-deep-cleaning-consent-form.png) ### Periodontal Deep Cleaning Consent Form A comprehensive consent form for periodontal deep cleaning procedures including scaling and root planing, anesthesia options, antibiotic therapy, and post-treatment maintenance schedules.](/templates/periodontal-deep-cleaning-consent-form/) [![Special Needs Dental Care Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/special-needs-dental-care-consent-form.png) ### Special Needs Dental Care Consent Form A comprehensive consent form for dental practices providing specialized care to patients with special needs, covering sedation options, medical accommodations, caregiver support, and desensitization protocols.](/templates/special-needs-dental-care-consent-form/) [![Tooth Extraction with Socket Preservation & Ridge Augmentation Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/tooth-extraction-with-socket-preservation-ridge-augmentation-consent-form.png) ### Tooth Extraction with Socket Preservation & Ridge Augmentation Consent Form Comprehensive informed consent and treatment planning form for socket preservation, ridge augmentation, membrane placement, and implant site development following tooth extraction.](/templates/tooth-extraction-with-socket-preservation-ridge-augmentation-consent-form/) [![Dental Extraction Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-extraction-consent-form.png) ### Dental Extraction Consent Form A comprehensive consent form for tooth extraction procedures that outlines procedure details, risks, post-operative care instructions, and tooth replacement options for informed patient decision-making.](/templates/dental-extraction-consent-form/) [![Dental Implant Treatment Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-implant-treatment-consent-form.png) ### Dental Implant Treatment Consent Form A comprehensive consent form for dental implant procedures including bone grafting acknowledgment, treatment risks, healing timelines, and detailed cost breakdown.](/templates/dental-implant-treatment-consent-form/) [![Dental Sedation Consent Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dental-sedation-consent-form.png) ### Dental Sedation Consent Form A comprehensive dental sedation consent form that captures medical history, fasting compliance, sedation level preferences, and transportation arrangements to ensure patient safety and informed consent.](/templates/dental-sedation-consent-form/) [![Dentist to Periodontist Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/dentist-to-periodontist-referral-form.png) ### Dentist to Periodontist Referral Form A comprehensive referral form for general dentists to refer patients to periodontists, including periodontal charting, pocket depths, bone loss measurements, and patient compliance details.](/templates/dentist-to-periodontist-referral-form/)