Consent For Root Canal Treatment (Endodontics) printable pdf download

Consent For Root Canal Treatment (Endodontics)

CONSENT FOR ROOT CANAL TREATMENT

(ENDODONTICS)

My dentist has suggested that a root canal treatment is an option for tooth #___

Alternatives to root canal treatment:

 Extraction

 Do Nothing



Other________________

Because of the wide differences among people and dental conditions, a successful outcome

cannot always be obtained. This is true even for routine procedures. Sometimes unexpected results

occur you should be aware of the potential before agreeing to continue.

Here are some of the more common (but not all) complications for root canal treatments.

 Pain, swelling, bruising, infection, prolonged bleeding

 Permanent or temporary numbness to the cheeks, lips, tongue, gums

 Small instruments breaking in the canals of the teeth

 Continued pain, leading to further surgery or the loss of the teeth

 Inability to fully treat the teeth due to curved roots, calcification in

canals or other complications

 Perforation of the roots by small instruments used during the procedure

 The tooth becomes more brittle, which may require inserting a post in

the tooth and crown later

 Overfilling the canals with inert material

Knowing that these risks exist and they might happen to me, I consent to allow the dental

office to perform a root canal treatment on the tooth indicated above.

______ I have been given the opportunity to ask questions about this procedure

and am fully satisfied with the answers I received.

_________________________

___________________________

Signature

Today’s Date

____________________________

Witness

I would like a copy of this form

> yes

> no

CONSENT FOR ROOT CANAL TREATMENT

Consent For Root Canal Treatment (Endodontics)