Information for dentist regarding root canal consent form
This document contains a free to download and use root canal consent form. The form is provided complimentary for use by dentists, endodontists or other dental specialists. It is provided courtesy of dentaldecider.com. The document can be downloaded as a pdf file or if you prefer simply edit and paste directly off of our website.
Guidelines for using root canal consent form
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ROOT CANAL CONSENT FORM
presented by dentaldecider.com in conjunction with Toothy Lane
This is an informed consent form to better inform patients of risks and benefits associated with root canal therapy. First, it discusses risks and benefits of anesthesia prior to performing your root canal. Next it discusses the benefits and risks of root canal treatment. Please read carefully and initial and sign where indicated. If you have any questions please ask your dentist before signing off on this consent form.
TEETH NUMBER(S) SCEHDULED FOR ROOT CANAL TREATMENT:
Teeth number(s): _____________________________________________
Patient initial: _________
____________ (patient initial) I understand that my dentist will be using local anesthetic along with epinephrine to numb up my mouth prior to performing a root canal treatment. I am aware of the risks and complications that are associated with using local anesthetics along with epinephrine. Risks include pain, allergic reaction, hematoma, elevated blood pressure, dizziness, fainting as well as anaphylactic shock (in rare cases).
ROOT CANAL TREATMENT CONSENT
____________ (patient initial) I am willingly and consciously giving my dentist informed consent to receive a root canal treatment. I have already been informed about success rates of root canal treatment. I understand that while success rates are high, root canals may still fail. This may require either redo of the root canal treatment or can cause me to lose my tooth altogether. However, I still would like to proceed with a root canal treatment with the full understanding of risks and possibilty of failure.
BENEFITS OF ROOT CANAL TREATMENT
- Removes tooth nerve and eliminates toothache resulting from a damaged or infected tooth
- Eliminates source of infection and gradually rids you of swelling and infection
- Allows you to keep infected or severely damaged teeth without having to remove the tooth itself
RISKS OF ROOT CANAL TREATMENT
- Root canal failure. If your root canal fails it must be either redone or your tooth must be removed. Redoing a root canal may include a referral to a dental specialist. Removing the tooth may also require a referral to a dental specialist. These can be long, drawn-out processes which can cause you to incur additional expenses.
- Pain after root canal treatment. While root canal treatments remove your tooth nerve, you may continue experiencing pain for a few days after treatment. There may be pain and swelling for several days afterwards.
- Infection, swelling and bruising of the endodontic therapy site. Taking antibiotics can help but it might not fully eliminate your problem.
- Drug reactions and side effects to the medications used for root canal treatment or those given to aid in the recovery process.
- Difficulty eating, chewing or even breathing for a while after your endondontic treatment.
- Accidental damage to the rest of your oral region. This can include laceration to your tongue, stretching of corners of mouth, cheek bruising and other traumas.
- Damage to any existing filling or crown on the tooth receiving endodontic therapy. Once you receive a root canal on any tooth, you may very likely have to redo the existing filling or crown. This is a financial risk that you assume responsibility for. Your dentist or endodontist performing root canal therapy can not be held responsible for any additional expenses you may occur restoring or removing your tooth subsequent to endodontic therapy.
- Jaw problems (Temporomandibular Joint or TMJ) known as Trismus. TMJ problems include limited opening of your jaws and soreness in the region. These symptoms may alleviate gradually over the course of a few months or they may be indefinite. Follow instructions and followup with your dentist for quicker recovery.
- Inability to complete fill the root canal. This may be for various reasons, such as your canal being calcified or having unique curvature. This may require a referral to a dental specialist or even the possibility of having to extract your tooth.
- Infection that may not fully clear and continue to reoccur. This may require further endodontic treatments or even the possibility of having to extract your tooth.
- There may be perforation or breakage of your tooth or its root during endodontic treatment. This may require a referral to a specialist, additional dental treatments or the possibility of having to remove your tooth.
- Inadvertent breakage of files or other instruments within the tooth root. Broken files and instruments must be retrieved to successfully complete your root canal. This may require a referral to a root canal specialist or in certain cases may mandated tooth removal.
- I understand that a root canal therapy only addresses tooth nerves. I understand that my tooth will require a filling, post or crown to restore its missing tooth structure which results from root canal therapy. I acknowledge that it is my responsibility to restore my tooth with a filling, post and/or crown before the tooth cracks or fractures. If I lose my tooth because of failure to restore the missing tooth structure in a timely fashion, then it is my sole responsibility. I will not be entitled to a refund if the root canal itself was a successful one.
I consent that I have thoroughly read and fully understand everything listed above. I understand that dentistry is not an exact science and that there are no guaranteed results. Additionally, I have asked any other questions and have received a satisfactory answer. I am prepared to have my root canal therapy with the full understanding of all possible risks and complications associated with this procedure.
Patient name: ______________________________________
If minor, guardian name: ____________________________________
Relationship to patient (minors only): ____________________________
Patient (or legal guardian) signature: ____________________________
Date : ________________
Witness name: _________________________________________________
Witness signature: __________________________________________________
Date : ________________
Doctor name: ____________________________________________________
Doctor signature: __________________________________________________
Date : ________________