Endodontic (Root Canal) Therapy Informed Consent

Endodontic (Root Canal) Therapy Informed Consent

Fairway Dental Clinic

385 Fairway Road South, Unit #203
Kitchener, Ontario, Canada N2C 2N9
Phone: 519-893-9494
Prior to undergoing Root Canal Therapy it is important that you read, understand and consent to the following:
- The alternative to Root Canal Therapy is usually Extraction
- The completed treatment usually takes between 1-3 visits
- There is a 5-10% chance that the root canal therapy may not work. Further dental treatment may be necessary in such cases.
- The treatment is generally painless but some discomfort may occur between visits which can be controlled pharmaceutically
- Existing restorations, crowns, veneers or tooth structure may break as a result of root canal therapy
- Instruments used to clean the tooth may break and/or perforate the internal part of the tooth
- Complications may be encountered due to difficult tooth anatomy, blocked canals, preexisting treatment, split tooth, breakage of instruments inside tooth or perforations of the tooth.
- Such complications may result in the necessity to extract the tooth, perform further dental treatment such as apical surgery and/or referral to endodontic specialist to complete the necessary treatment
- Crown with or without post/core is strongly recommended to reduce the chance of fracture of the root canal treated tooth
- The treatment has been discussed with my dentist and any additional questions and concerns have been addressed
Consent*
I HAVE READ AND UNDESTAND THE ABOVE INFORMATION AND WISH TO PROCEED WITH THE ROOT CANAL THERAPY ON TOOTH
Patient’s Name*
.
Tooth No (s)*
Please enter a number(s) from 1 to 48.
Date*
.
DD slash MM slash YYYY
Patient’s Signature*
(Write Your Name)
Dentist/Treatment Coordinator*
(Write Your Name)
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Endodontic (Root Canal) Therapy Informed Consent

Fairway Dental Clinic