CONSENT FOR ROOT CANAL TREATMENT - PDF Document

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  1. CONSENT FOR ROOT CANAL TREATMENT I hereby authorize Dr_________________to perform a root canal on tooth number(s): #_________ The doctor has explained to me that the purpose of this procedure is to retain teeth that may otherwise have to be extracted. The doctor has explained to me the treatment and the anticipated results of the treatment. I understand that this is an elective procedure and that there are alternative treatments and the doctor has explained the risks and benefits of the alternatives. I understand that root canal therapy has a very high success rate, but the doctor has not guaranteed or warranted a perfect result. The doctor has explained to me that there are certain potential risks in the procedure. These include: Inability to completely fill the root canal because the canal is calcified or has a unique curvature (This may require endodontic surgery or extraction of the tooth) Infection that may occur and may continue, requiring further endodontic surgery or extractions. Fracture or breakage of the root or crown portion during or after treatment Inadvertent breakage of files or instruments within the root canal system that are unable to be retrieved Perforation of the tooth during treatment Damage to existing fillings, crowns or porcelain veneers Post-op pain that may last for several months which require antibiotic and adjustment I understand that I need a crown after root canal treatment. If my root canal treated tooth/teeth had re-infection within two years and after completion date, the practice will refund my copay if I has been insured at the time of treatment. If I am self-pay at the time of treatment, then the practice will refund 35% of my root-canal fee. And I can use my refund toward the next treatment option. I’ve foreseen conditions may arise that require a procedure that is different than set for the above or a referral to a specialist. I authorize the doctor and any associates to perform such procedures when, in their personal judgment, the procedures are necessary. I understand that the medications, drugs, anesthetics and prescriptions taken for this procedure may cause drowsiness and lack of awareness and coordination. I further understand that drugs and anesthetics may cause unanticipated reactions, which might require medical treatment. I also understand that I should not consume alcohol or other drugs at the same time because they can increase these effects. I have been advised not to work and not to operate any vehicle or machinery until I have fully recovered from the effects of the medications. __________________________ Patient’s Signature Date ___________________________ __________________________ ___________________________ Dentist’s Signature Witness: