Address: 4300 S Park Dr #270, Stony Plain, AB, T7Z 2W7, CA
Telephone: (780) 968-4414

Root Canal Treatment Consent Form

ENDODONTIC (ROOT CANAL) TREATMENT CONSENT
Please read and consent to all the information below and feel free to ask any questions you may have.
Treatment Awareness*
I understand the nature of my oral condition and the purpose of the proposed endodontic treatment (“RCT”), which was explained to me in detail. I am aware that alternatives to RCT include the following: endodontic surgical treatment (if applicable), extraction, and no treatment. All applicable treatment options, including specialist referral, have been discussed with me.
Guarantee*
I understand that a very high percentage of routine RCT procedures are successful and have a good long-term prognosis, however, since it is a biological procedure, this cannot be guaranteed.
Treatment Success*
I understand the success of RCT is influenced by many factors, which include but are not limited to the following: my general health, adequate gum attachment/bone support, shape and condition of the roots and nerve canal(s), pre-existing root fracture, and the (rare) presence of resistant bacteria.
Associated Risks*
I understand that certain risks and/or complications are associated with the RCT, which include but are not limited to the following: post-op discomfort, post-op swelling, internal/external resorption, and temporomandibular joint trauma/soreness.
Procedural Errors*
I understand that certain procedural errors may occur. These include but are not limited to:
1) Perforation of the root canal: may require additional surgical correction treatment or result in premature tooth loss leading to extraction. Repair of the perforation may require an endodontist. The patient is responsible for all fees related to the repair of the perforation.
2) Instrument separation: the dentist will attempt to remove the broken instrument. If attempted removal is unsuccessful, specialist referral may be necessary. Surgery of the bottom of the root may be required for successful completion of the case, or the tooth may have to be extracted. All related fees will be the responsibility of the patient.
Fracture Risk*
I understand that following RCT, the tooth may become brittle and be susceptible to fracture or decay. In almost all cases, a crown, post and core will be necessary to restore normal tooth function and strength. A filling may be used if the dentist deems it more appropriate for the given case. Failure to place the appropriate restoration could result in failure of the RCT, tooth fracture and possibly extraction. Rarely, the tooth can fracture despite placement of a crown.
Post Op Visits*
I understand that post-op visits are needed to monitor success of the RCT and must be attended at six (6) months and one (1) year post-op. In most cases, monitoring will occur at your regular recall or examination appointments. Failure to attend recall appointments may result in abscess and possibly disabling infection.
Decay*
I understand RCT teeth can become decayed. To avoid this, proper oral hygiene (brushing and flossing) is necessary. In addition, regular dental exams will help preserve normal tooth function and strength.
Endodontic Consent*
I have read and understood the risks and complications which may occur in connection with this procedure. I have been given this form prior to the initiation of RCT. I understand the potential risks are not limited to those described above. I agree that I have been given and understood enough information to give my consent for the above procedure and to any other treatment or service deemed necessary or advisable. I understand the importance of post-procedure restoration (i.e., a crown, in most cases) and my responsibility to contact the dental office should any unexpected problems occur. I have had the opportunity to ask questions and all such questions have been answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I authorize and agree to undergo the RCT.
Treatment Provided by:*
Tooth*
Please ask the office staff for more details
Today's Date*
Name*
First Name Last Name
Patient/Guardian Signature*

Mon	8:00 AM - 4:00 PM
Tues	7:30 AM - 3:30 PM
Wed	9:00 AM - 6:00 PM
Thurs	9:00 AM - 6:00 PM
Fri	8:00 AM - 3:30 PM
Sat-Sun	Closed

ENDODONTIC (ROOT CANAL) TREATMENT CONSENT