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Paradise Smiles Dentistry, PC Consent for Root Canal Treatment
Patient’s Name: ___________________________________________ I understand that many factors contribute to the success of root canal treatment and not all factors can be determined in advance, if ever. Some of the factors are: my resistance to infection; the specific bacteria causing the infection; the size, shape and location of the canals; the force with which I bite. I understand that my case may be more difficult if my tooth has blocked canals, curved canals, or very narrow canals. I understand that root canal treatment may not relieve my symptoms, that treatment can fail during or after completion of treatment; and that it may fail for unexplainable reasons. If treatment fails, other procedures (including root canal retreatment and/or oral surgery) may be necessary to attempt to retain the tooth, or it may have to be extracted. I understand that I will be given a local anesthetic injection and that in rare instances patients have had an allergic reaction to the anesthetic, an adverse reaction to the anesthetic, or temporary or permanent injury to nerves and/or blood vessels from the injection. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from holding my mouth open during treatment. I understand that once root canal treatment is completed, I must promptly return to begin the next step in treatment. If I fail to return to have the tooth restored, I risk a failure of the root canal treatment, decay, infection, and tooth fracture and loss of the tooth. Other foreseeable risks not stated above include: _________________________________________________ _______________________________________________________________________________________________ ______ I have had an opportunity to ask questions about these risks and any other risks I have heard or thought about, Patient’s Initials including _________________________________________________________.
Acknowledgement I have provided as accurate and complete medical and personal history as possible including antibiotics, drugs, or other medications I am currently taking as well as those to which I am allergic. I will follow any and all treatment and post-treatment instructions as explained and directed to me and will permit the recommended diagnostic procedures, including x-rays. I realize that in spite of the possible complications and risks, my recommended root canal treatment is necessary. I am aware that the practice of dentistry is not an exact science and I acknowledge that no guarantees have been made to me concerning results of the treatment. I ___________________________, have received information about the proposed treatment with Dr. Dentremont and have been given an opportunity to ask questions and have them fully answered. I understand the nature of the recommended treatment, alternate treatment options, and the risks of the recommended treatment. I wish to proceed with the recommended treatment. ______ I understand this treatment can also be performed by an endodontist (a root canal specialist). I understand the risks and elect to have this procedure done by Dr. Dentremont. I understand that if any unexpected difficulties occur during treatment, I may be referred to an endodontist for further care of this tooth.
Signed: _______________________________________ Date: ___________________________ Patient or Guardian Signed: _______________________________________ Date: ___________________________ Treating Dentist Signed: _______________________________________ Date: ___________________________ Witness
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