Root Canal Treatment Consent Form printable pdf download

Root Canal Treatment Consent Form

Patient’s Name: ______________________________________

Chart #: _________

TX Date: ____________

Tooth No.: _______

Procedure: _____________________

Risks of Endodontic Treatment



I understand that many factors contribute to the success of root canal treatment and not all

factors can be determined in advance. Some of the factors are: my resistance to infection;

the bacteria causing the infection; the size, shape and location of the canals. My case may be

more difficult if my tooth has blocked, curved or narrow canals.



I understand that root canal treatment may not relieve my symptoms and treatment can

sometimes fail for unexplained reasons. If treatment fails, other procedures (including re-

treatment or surgery) may be necessary to retain the tooth or may have to be extracted.



I understand that during and after treatment, I may experience some pain or discomfort,

swelling, bleeding and loosening of dental restorations. I may also need antibiotics to treat

any associated infections.



I understand that root canal instruments sometimes separate (break) inside the canal which

may or may not affect the prognosis. If the separated fragment cannot be retrieved, it may

be sealed inside the root canal or require additional treatment in the future.



I understand that other risks include perforation by the instrument, sinus perforation and/or

nerve disturbances.



I understand local anaesthetic will be given. Some discomfort following treatment may

develop from the injection area and from opening my mouth during treatment. On rare

occasions, paresthesia of the nerve may occur.



I understand that once root canal treatment is completed, I must have a permanent

restoration placed by my regular dentist within a few weeks. If I fail to have the tooth

restored, I risk a failure of the root canal treatment, decay, infection, tooth fracture and/or

loss of the tooth.

Alternatives to Endodontic Treatment

Depending on my diagnosis, there may be alternatives to root canal treatment that involve other

types of dental care. I understand the most common alternatives to root canal treatment are:



Extraction. I may choose to have this tooth removed. The extracted tooth usually requires

replacement by artificial tooth by means of a fixed bridge, dental implant, or removable

partial denture.



No treatment. I may choose to not have any treatment performed at all. If I choose no

treatment, my condition may worsen and I may risk serious personal injury. Including sever

pain, localized server pain, localized infections, loss of this tooth and possible other teeth,

severe swelling, and/or severe infection that may spread to other areas and could be

potentially fatal.

I acknowledge that I have provided an accurate medical history, will follow treatment

recommendations and have had the opportunity to ask questions about these risks in continuing with

root canal treatment.

Patient’s Signature: ______________________________________________ Date: _______________

Parent/Guardian: ______________________________________________

Date: _______________

Provider’s Signature: ____________________________________________

Date: _______________

Root Canal Treatment Consent Form

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