This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable as a corollary to the planned endodontic therapy performed by Endodontic Associates and any assistant the may require. I agree to the use of local anesthesia sedation, and/or analgesia, depending upon the judgement of the endodontist. Complications of root canal therapy and anesthesia may include swelling, discomfort, infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent.
I understand root canal therapy is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require retreatment, surgery, or even extraction.
I understand that Endodontic Associates is not financially responsible to any damages to existing restorations. which include but are not limited to crowns and bridges. During the procedure the restoration could fracture, become loose, or come off completely and will necessitate to be replaced.
I also understand that only the root canal therapy is to be performed at this office. The permanent (outside) restoration (filling, onlay, crown, etc.) will be done by my regular dentist.
I understand that medications for pain and sedation may cause drowsiness which can be increased by the use of alcohol or other drugs. I will avoid operating any vehicle or hazardous devices while taking such medications. I further understand that certain medications may cause hives and intestinal problems and, if any of these reactions occur, I am to call the doctor immediately. I understand that it is my responsibil- ity to report any changes in my medical history.
All reasonable collection and/or legal costs required to collect fees due Endodontic Associates will be borne by the undersigned. ALL SIGNATURES MUST BE BY PARENT OR GUARDIAN IF PATIENT IS 18 YEARS OR YOUNGER.