Endodontic Treatment Informed Consent Agreement

Patient Information

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

Treatment Consent

I, _________________________, hereby authorize Dr. _________________________ and any associates to perform endodontic treatment (root canal therapy) on tooth/teeth number(s): _________________

Understanding of Procedure

1. I understand that root canal therapy is a procedure to retain a tooth which may otherwise require extraction
2. Treatment will involve removing the damaged pulp (nerve and blood vessel tissue) from within the tooth and its root(s)
3. The root canal system will be cleaned, shaped, and filled with biocompatible materials

Risks and Complications

I understand that complications may arise, including but not limited to:

• Persistent pain or sensitivity
• Infection requiring additional treatment
• Instrument separation within the canal
• Perforation of the root or crown
• Damage to existing restorations
• Possibility of unsuccessful treatment requiring retreatment, surgery, or extraction

Post-Treatment Care

I acknowledge that:

1. A permanent restoration (crown or filling) will be necessary following treatment
2. Failure to complete the restoration may result in tooth fracture or treatment failure
3. Regular dental check-ups are essential for maintaining treated teeth

Financial Agreement

• Estimated cost of treatment: $_________________
• I understand insurance coverage may vary and I am responsible for full payment

Signatures

Patient/Guardian Signature: ___________________ Date: ___________

Witness: __________________________________ Date: ___________

Dentist: __________________________________ Date: ___________