Endodontic Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: _________________

Treatment Plan

Tooth/Teeth Number(s): ___________

Agreement Terms

1. Nature of Endodontic Treatment

I understand that root canal therapy is a procedure to retain a tooth which may otherwise require extraction. The procedure includes:

• Removing infected or damaged pulp tissue
• Cleaning and shaping the root canal system
• Filling and sealing the root canals

2. Expected Outcomes and Alternative Treatments

I acknowledge that:

• Success rates for root canal therapy are approximately 90-95%
• Alternative treatments include:
  • Extraction of the tooth
  • No treatment
  • Waiting for more definitive symptoms to develop

3. Risks and Complications

I have been informed of potential risks including:

• Instrument separation in the canal
• Perforations of the crown or root
• Damage to existing restorations
• Post-operative discomfort
• Possibility of failure requiring retreatment, surgery, or extraction

4. Post-Treatment Responsibilities

I agree to:

• Complete the recommended permanent restoration within 30 days
• Return for all scheduled follow-up appointments
• Contact the office immediately if complications arise

5. Financial Agreement

• I understand the estimated cost of treatment: $_________
• I acknowledge insurance coverage may vary
• Payment is due at time of service unless other arrangements are made

Signatures

Patient/Guardian: _________________ Date: _________

Provider: _______________________ Date: _________

Witness: ________________________ Date: _________