Please review the following informed consent and sign prior to the initiation of treatment.

I give consent to take any radiographs (xrays), administer any medications, anesthetics, drugs, and services or procedures deemed necessary or advisable as a corollary to the endodontic treatment. 

I understand that endodontic therapy is a procedure to retain a tooth that may otherwise require extraction and that only endodontic therapy and associated procedures will be performed. Endodontic therapy involves the removal of the pulp tissues (nerves and blood vessels) from inside the tooth and is then sealed with a temporary filling material.  Endodontic therapy holds a high degree of success, but because it is a biological procedure, success cannot be guaranteed. Occasionally, an endodontically treated tooth may require re-treatment, periradicular surgery, or even extraction. During treatment, there is also the possibility of instrument separation within the tooth, perforation of tooth structure in gaining access to the tooth canals, and fracturing of the tooth. Following therapy, the tooth must be restored to function with protective restoration – usually via post and crown. Some teeth may not be amenable to endodontic therapy at all. Other treatment options include no treatment, waiting for more definitive symptoms, or tooth extraction. Risks involved in these choices include (but not limited to) pain, swelling, loss of tooth, infection, and risk of infection spreading to other areas.

Complications of endodontic therapy and anesthesia include(but not limited to) swelling, pain, infection, trismus(restricted jaw opening), bleeding, sinus involvement, and numbness of the lip, gum, or tongue. Numbness is usually temporary and rarely permanent. 

The nature of endodontic therapy has been explained to me, and I have had the opportunity to have my questions answered to my satisfaction regarding the nature of my treatment.

Doctor Signature: On File