Consent for Root Canal Treatment Form

The intended benefit of root canal treatment is to relieve my current symptoms, treat an infection, or permit me to continue with additional treatment needed.

Risks of root canal treatment include, but are not limited to the following:

• A separated (broken) instrument in the tooth, which may prevent successful treatment
• Perforation of the tooth or tooth root by an instrument
• Damage to existing crowns, bridges, or other appliances
• Post-operative pain, swelling, and/or infection
• Failure of the treatment
• Blocked canals that may prevent successful treatment
• Identification of crown or root fracture during or after treatment, requiring tooth extraction

I understand that root canal treatment may not relieve my symptoms, and that treatment can fail during or after completion of treatment. If treatment fails, other procedures, including root canal treatment or oral surgery, may be necessary to attempt to retain the tooth, or it may require extraction.

I understand that once root canal treatment is completed, the tooth will need a final restoration, usually a crown, to return it to proper function. If I fail to return promptly to have the tooth restored, I risk a failure of the root canal treatment, decay, infection, and tooth fracture or loss of the tooth. I understand this procedure will not prevent future tooth decay.

I understand there are alternatives to root canal treatment including:

1. NO treatment
2. Extraction and no tooth replacement
3. Extraction with tooth replacement

I acknowledge that no guarantees have been made concerning the results of treatment. My questions have been answered by the dentist and I fully understand the statements contained in this form.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.