Dental Treatment Informed Consent Form

Dental Informed Consent Form

Root Canal Therapy
Patient Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email
example@example.com
Is the patient minor? *

Yes No
Parent/Guardian Information
Parent/Guardian Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Dental Procedure Details
Confirm Dental Procedure *

Root Canal
Please confirm the tooth requiring treatment: *
A tooth number should be used
INFORMED CONSENT FOR ENDODONTIC (ROOT CANAL) THERAPY

Root canal treatment works by removing bacteria from the hollow space inside the tooth, and by sealing off the inside of the tooth to prevent re-infection. Although root canal therapy has a very high success rate, it is a biological procedure and cannot be guaranteed. Occasionally, a tooth which has had root canal treatment may require retreatment, additional surgery, or extraction.

I understand the possible risks of root canal therapy, although rare, do exist. They include (but are not limited to) pain, infection, swelling, fever, changes in occlusion (bite), temporal mandibular (jaw) joint pain, and difficulty opening and closing. I understand the alternatives to root canal treatment are extraction of the involved tooth or postponement of root canal therapy.

I realize that postponement of treatment may result in future loss of the tooth.

I understand the possible complications of root canal therapy, although rare, do exist. They include (but are not limited to) instrument breakage in the root canal, inability to negotiate canals due to prior treatment or calcification, perforation to the outside of the tooth, irreparable damage to the existing crown or restoration, and cracking or fracturing of the root or crown of the tooth.
Acknowledgment and Waiver
*

I allow and authorize Steven P. Goguen, DMD to perform this procedure to me. The doctor explained the nature of the treatment and how it will help me. I allow Steven P. Goguen, DMD, PC to administer anesthesia and understands the side effects of the medications given to me. I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups. I acknowledge that all information I provided int his form is true and accurate.
Patient/Parent/Guardian Signature *

Clear
Signed Date

Month Day Year
Date
Should be Empty:

Dental Informed Consent Form

Patient Information

Parent/Guardian Information

Dental Procedure Details

Acknowledgment and Waiver