Form

INFORMED CONSENT FOR ROOT CANAL THERAPY

This is my consent for

To perform the following treatment/ procedure:

I understand that the purpose of the procedure is to treat and possibly correct my diseased oral/maxillofacial tissues. I have been advised that if this condition persists without treatment, my present oral condition will probably worsen in time, and the risks to my health may include, but are not limited to the following: swelling, pain, infection, cyst formation, malocclusion, premature loss of teeth, and/or premature loss of bone. I have been informed of possible alternative methods of treatment, if any.

The Doctor has explained to me that there are certain inherent and potential risks in any root canal treatment (including the administration of any necessary local anesthesia) which include, but are not limited to:

1. Postoperative discomfort and swelling that may persist for several days.

2. Stretching of the corners of the mouth will result in cracking and bruising.

3. Injury to the nerve underlying the teeth resulting in numbness or tingling of the lip, chin, gums, cheek, teeth, and/or tongue on the operated side: this may persist for several weeks, months, or in some instances permanently.

4. Reinfection of the canal and/or surrounding supporting tissue requiring treatment.

5. Inability to reach and treat the end of the root.

6. Abscess of cyst formation.

7. Perforation of the side of the root.

8. Calcification or closure of the canal.

9. Fracture of the root.

10. Discoloration of the tooth.

11. Broken file lodged in canal.

12. Other

The Doctor has explained to me that root canal treatment is usually performed in two stages:

Removal of the infected pulp and cleaning of the canal
Sealing the canal to prevent infection and restoring the tooth.

I understand that unless both steps are completed, the tooth can become reinfected which can lead to general health complications and the loss of the tooth. Therefore, it is essential that I complete the tooth. therefore, it is essential that I complete the root canal once the treatment is initiated in a timely manner (usually 1 to 4 weeks); OTHERWISE, THE FIRST STAGE OF TREATMENT MAY NEED TO BE REPEATED, INCURRING ADDITIONAL FEES. No guarantee or assurance has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. Due to individual patient differences there exists a risk of failure, relapse, selective retreatment, or worsening of my condition would occur sooner without the recommended treatment. Because successful treatment often depends upon compliance with a doctor's instructions, I agree to cooperate completely with the recommendations of the doctor and/or his/her assistant while I am under his/her care, realizing that any lack of the same could result in a less than optimum result.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION AND THE EXPLANATION REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN ANS INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED.

I ALSO STATE THAT I READ AND WRITE ENGLISH.

Witness

Patient, Parent, or Guardian

Date

First Name

Last Name

Date Of Birth