Endodontic (RCT) Therapy Informed Consent

This form and your discussion with the dentist are intended to help you make an informed decision about the endodontic (Root Canal) procedure. As a member of the treatment, you have been informed of your diagnosis, planned procedure, risks/benefits, and alternatives associated with the procedure as well as associated cost. In order to increase the chance of achieving optimal results, you have provided an accurate and complete medical history, including all past and present medical and dental conditions, prescription and non-prescription medications, any allergies, recreational drug use, and pregnancy (if applicable). You dentist will be happy to answer any questions you may have and provide additional information before you decide to sign this document and move forward with the procedure.

I have been informed of an understand the potential risks related to this procedure which include but are not limited to:

Post-treatment discomfort, incomplete treatment due to blocked canals, recurrent infections, gum irritation, damage to adjacent teeth, fracture of existing crown, temporary or permanent numbness, instrument separation in the canal, perforations (opening) of the tooth root, cracking and/or stretching of the corners of the mouth, stress to the jaw joint (TMJ), altered bite, change in esthetic appearance of teeth, allergic and/or allergic reactions to medications and/or materials. In case of unforeseen complications, I might have to be referred for advanced care.

This procedure will not prevent future tooth decay, tooth fracture or gum disease. Occasionally, a tooth that has had a Endodontic (Root Canal) treatment may require re-treatment, endodontic surgery or tooth extraction.

I have been informed of an understand that follow-up visits or care, additional evaluation and/or treatment may be needed.

I understand the use of tobacco and alcohol is detrimental to the success of my treatment.

I agree to follow all instructions provided to me by this office before and after the procedure, take medication(s) as prescribed, practice proper oral hygiene, keep all appointments, make return appointments if complications arise, and complete care. I will inform my dentist of any post-operative problems as they arise. My failure to comply could result in complications or less than optimal result.

I understand and accept that the dentist cannot guarantee the results of the procedure. I had sufficient time to read this document, understand the above statements, and have had a chance to have all my questions answered to my satisfaction. By signing the document, I acknowledge and accept the possible risks and complications of the procedure and agree to proceed.