Download root canal informed consent form

 ROOT CANAL INFORMED CONSENT FORM 1. The purpose of root canal therapy is to retain teeth that would otherwise have to be extracted. 2. Treatment will require a series of diagnostic radiographs and may require multiple visits. It is important that you maintain scheduled appointments or the infection can re-­‐occur. 3. In most cases, there is only mild discomfort following treatment. This can usually be controlled with Advil, Tylenol or Aspirin. 4. Endodontic therapy has a high degree of success (approximately 90-­‐95%). As with any medical or dental treatment, however, this treatment has no guarantee of success in retreatment. Teeth with previous root canal treatment tend to have a lower success rate. 5. Accurate and complete disclosure of medical information is necessary for proper diagnosis and to help prevent unnecessary complications during your treatment. 6. The most common complications with root canal therapy include but are not limited to: • Continued infection requiring surgery or extraction of the tooth • Calcified canals or canals blocked by separated instruments requiring surgery or extraction of the tooth • Tenderness of the tooth following treatment due to gum disease, physical stress from chewing, or poor healing • Fractures (breaking) of the root or crown of the tooth during or after treatment. It is recommended that all posterior teeth be crowned following root canal treatment. If your tooth already has a crown, there is a chance it will need to be replaced due to decay or loss of structural support. • Pain, requiring use of medication 7. Other treatment choices include no treatment, wait for a more definite development of symptoms and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth and infection to other areas. Informed Consent: I have been given the opportunity to ask any questions regarding the nature and purpose of root canal therapy and have received answers to my satisfaction. I assume any possible risks, which may be associated with any phase of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered to me. By signing this form, I am giving my consent to allow and authorize Dr.____________________________ at Capital Dental Centre to render any treatment necessary or advisable to my dental conditions, including any anesthetics and/or medications. __________________________________________________________________________________________ Patient’s Name Signature of Patient Date If patient is unable to sign, or is a minor-­‐ signature of parent or legal guardian Signature of Doctor Date Signature of Witness Date Capital Dental Centre 3-­‐3320 McCarthy Road Ottawa, Ontario K1V 0X3 613.526.9876