Endodontic Treatment Informed Consent Form

Patient Information

Name: ___________________________ Date: _______________ Date of Birth: ____________________ Chart #: _____________

Nature of Endodontic Treatment

I understand that root canal therapy is a procedure intended to retain a tooth that may otherwise require extraction. I have been informed that the following will be performed:

• Removal of inflamed or infected pulp tissue from within the tooth
• Cleaning and shaping of root canal system(s)
• Filling and sealing of the root canal system(s)
• Placement of a temporary filling

Risks and Complications

I acknowledge that I have been informed of the following potential risks:

1. Procedural Complications

   • Broken instruments
   • Perforations
   • Missed canals
   • Canal blockage

2. Post-Treatment Issues

   • Temporary pain/discomfort
   • Infection/swelling
   • Need for additional procedures
   • Tooth fracture

Alternative Treatments

I understand the alternatives to root canal therapy include:

• Extraction of the tooth
• No treatment
• Waiting for more definitive symptoms

Post-Treatment Responsibilities

I understand that:

• A permanent restoration (crown) is typically necessary after treatment
• Follow-up appointments are essential
• Proper oral hygiene must be maintained

Financial Responsibility

I understand that I am responsible for payment of services rendered and that this procedure may not be covered in full by my insurance.

Consent

I certify that I have read and fully understand the above information. I have had the opportunity to ask questions, and all my questions have been answered satisfactorily.

Patient/Guardian Signature: __________________ Date: __________

Witness: __________________________________ Date: __________

Dentist: __________________________________ Date: __________