Download Consent for Endodontics/Root Canal Therapy

Mariah A Shojaei DMD, MSc, MSD, MBA, PC
46161 West Lake Dr., Suite #120 | STERLING VA, 20165 | (703) 406 -3180
ENDODONTIC (ROOT CANAL) CONSENT AND INFORMATION FORM
Endodontic or root canal therapy is the cleaning, shaping, disinfecting, and filling of the root canal(s) of the diseased tooth. A treated
tooth usually functions normally as a pulp less tooth, not a dead tooth. Treatment will usually require one or more visits depending
upon condition of the tooth and may need additional x-rays to be taken.
Following treatment, the tooth will be brittle and subject to fracture. A restoration (filling), crown, and/or post and core will be
necessary to restore the tooth to function (these procedures would be performed by your general dentist). The alternatives to
Endodontic therapy include: no treatment, waiting for more definite development of symptoms, and/or tooth extraction. The risks
involved for these options might include pain, infection, swelling, and tooth loss.
Please be advised of the following:
1.
As a rule, 90 to 95% of routine cases are successful. There will be a full charge for all completed cases regardless of success or
failure. No warranty or guaranty of success can be given in root canal treatment. If the original treatment is not successful, it
may have to be redone, a surgical procedure may be required, or the tooth may need to be removed (an additional fees will be
charged for each of this procedure). In the event that any of these occur or the treatment cannot be completed due to
complication, you may need to be referred to a specialist, there will be a charge for all procedures performed to that point.
2.
Possible unavoidable complications of Endodontic therapy may include, but not limited to the following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Procedural difficulties in the course of treatment.
Swelling, soreness, infection, trismus (restricted jaw opening) or discoloration of the soft or hard tissue.
Breakage of root canal instruments during treatment, which may in the judgment of the doctor be left in the treated root
canal or require surgery for removal.
Fracture of the crown or root of the tooth.
Perforation of the root canal with instruments, which may require additional surgical corrective treatment or result in
premature tooth loss or extraction.
Under fill and/or overfill of the canal.
Sinus perforation.
Damage to bridges, existing fillings, crowns.
Blocked canals due to fillings or prior treatment, natural calcification, severely curved roots, and root resorption.
Premature tooth loss due to progressive periodontal (gum) disease.
After completion of root canal therapy, sensitivity to cold and hot will disappear but sensitivity to biting may continue.
3.
There is a greater chance of failure of root canal therapy if patient fails to keep scheduled appointments. If there is more than a
month time lapse, the patient will be charged an additional $100.00 to continue root canal therapy.
4.
Take pain medication as directed when you first feel discomfort. Pay attention to any warnings on the medication container from
the pharmacy. If antibiotics are prescribed, it is very important that you take all of them as directed.
I ___________________________ have been advised by Dr._______________________ that I require a root canal
treatment for my tooth/teeth _____________.
I understand that I am to contact this office for an evaluation visit, three months and one year after treatment is completed, so
that the root can be evaluated (not included in fees).
I understand that it is my responsibility to set up and follow through with all appointments. Failure to do so may result in loss
of tooth or damage to other teeth and surrounding bone.
The doctor has answered all of my questions and I fully understand the above statements in the consent form. I hereby give
my consent to perform this procedure on me as listed above. I further give my consent for administration of medications, local
anesthetics, and services deemed necessary to treat my Endodontic problem, understanding that risks are involved. I also
understand that I may get additional information and have my questions answered prior to, during, or after treatment merely
by asking.
__________________________________
Signature of Patient or legal Guardian
________________
Date
_______________________
Doctor’s Signature