Endodontic Treatment Authorization Form

I, _________________________, hereby authorize Dr. _________________________ and their clinical staff to perform endodontic treatment (root canal therapy) on tooth/teeth number(s): __________.

Nature of Endodontic Treatment

• I understand that root canal therapy is a procedure to retain a tooth that may otherwise require extraction
• Treatment involves removing the damaged pulp (nerve and blood vessel tissue) from within the tooth and its root(s)
• The cleaned canal space will be filled with a biocompatible material

Risks and Complications

I understand that complications may include, but are not limited to:

1. Post-treatment discomfort lasting several days
2. Infection requiring additional treatment
3. Fracture of the tooth requiring additional treatment
4. Separation of dental instruments within the root canal
5. Perforation of the root canal
6. Damage to existing restorations

Additional Treatment

I understand that:

• Root canal treatment is one step in the total treatment plan
• A permanent restoration (crown or filling) will be needed
• Additional procedures may be necessary if complications arise

Financial Responsibility

I acknowledge my responsibility for payment of the endodontic treatment in accordance with the office's fees and policies.

Consent

I have read and understand the above information and have had the opportunity to ask questions. I hereby give my consent to perform the endodontic treatment.

Patient/Guardian Signature

Date

Witness