Consent For Root Canal Treatment
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1Advanced Dental & Denture
th
9835 16
Ave SW, Suite 101, Seattle, WA 98106
Phone: (206) 763-8883 Fax (206) 786-8887
CONSENT FOR ROOT
CANAL TREATMENT
Patient name_______________________________________________________________________________ I hereby authorize
Doctor name _______________________________________________________________________________ and any associates
To perform a root canal on tooth/teeth number(s):_______________________________________________________________
The doctor has explained to me that the purpose of this
procedure is to retain teeth that may otherwise have to be
2. Infection that may occur and may continue,
extracted. The doctor has explained to me the treatment
requiring further endodontic surgery or
and the anticipated results of the treatment. I understand
extraction.
that this is an elective procedure and that there are
3. Further or breakage of root crown portion during
alternative treatments, and the doctor has explained the
or after treatment.
risks and benefit of the alternatives. I also understand that
4. Inadvertent breakage of files or instruments
the root canal therapy has a very high success rate, but the
within the root canal system that are unable to be
doctor has not guaranteed or warranted
retrieved.
a perfect result.
5. Perforation of the tooth during treatment.
6. Damage to existing fillings, crowns, or porcelain
The doctor has explained to me that there is certain
veneers.
potential risk in procedure. These include:
1. Inability to completely fill the root canal because
7. _________________________________________
the canal is calcified or has a unique curvature.
This may require endodontic surgery or
_________________________________________
extraction of the tooth.
_________________________________________
Unforeseen conditions may arise that require a procedure
unanticipated reactions, which might require medical
that is different than set forth above or a referral to a
treatment. I also understand that I should not consume
specialist to perform such procedures when in their
alcohol or other drugs because they can increase these
professional judgment, the procedures are necessary.
effects. I have been advised not to work and not to operate
any vehicle or machinery until have fully recovered from
I understand that the medications, drugs, anesthetics, and
the affect of the medications.
prescriptions and lack of awareness and coordination, I
Please do not hesitate to ask the doctor or the staff if you
have any questions.
further understand that drugs and anesthetics may cause
____________________________________________________________________________________________________________
Patient, parent or guardian
__________________________________________________________
__________________________________________
Doctor
Date
2013-08-16
CONSENT FOR ROOT CANAL TREATMENT
Page 1
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