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Download Informed Consent for Endodontic (Root Canal) Treatment
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3476SouthHighStreet Columbus,Ohio43207 Tel:614-497-0012 Fax:614-497-1525 Dr.MattPaulson GeneralDentist www.drmattpaulson.com InformedConsentfor Endodontic(RootCanal)Treatment The Doctor has explained the benefits and risks of root canal treatment to me. Referral to a specialist (endodontist)hasbeenoffered.Iunderstandthatrootcanaltreatmentinvolvestheremovaloftissuesin the center of the tooth (root canal) and the sealing of the space that is created during the process of removalandcleansingoftherootcanalsystem.Ifurtherunderstandthattherootcanaltreatmentmay failifaproperfillingorcrownisnotcompletedaftertherootcanalisdone,andthatsuchrestorationisa separateanddistinctprocedurewithanadditionalfee. I understand and accept the treatment recommended for me by the Doctor. I further understand that theremaybesomeunwantedcomplications,someofwhicharelistedbelow.Noguaranteeshavebeen madeorimplied**.Alternativetreatment(s)andtheoptionofnotreatmenthasbeenexplainedtome.I understand that an alternative treatment may include extraction of the involved tooth or teeth. I understand the risks of no treatment include, but are not limited to infection, swelling, cyst formation, pain,lossoftooth/teethand/orsystemicdisease.Allofmyquestionshavebeenaddressed. Tooth/teethinvolvedintreatment:________________ Treatmentrisks/unwantedconsequencesmaybe(butarenotlimitedto): • Reactiontomedications/anesthetic • Temporaryorpermanentnumbnessortinglingofthelip,chin,tongueorotherareas • Potentialforre-treatmentofrootcanalorpossiblesurgicaltreatment • Instrumentbreakageinthetooth/perforationoftheroot(s) • Recurrentdecay • Coloroftoothmaychange(becomedarkerthanadjacentteeth) • Posttreatmentswellingand/orpain • Rootfracture/crownfracture • Needtoextracttooth Patientsignature Date Witness **While most root canal treatments are successful, there is a 4-6% failure rate resulting in retreatment at a specialist (endodontist) at his/her additional fee or loss of tooth. If the tooth requiresextractionwithinoneyearoftreatment,therewillbenoadditionalfeefortheextraction. Updated9/12/16
