ROOT CANAL CONSENT FORM

I hereby acknowledge that I have consulted with my dentists, who have provided me with a detailed explanation of my condition requiring endodontic (root canal) therapy. I understand that dentistry involves professional judgment and is not an exact science. Therefore, no guarantees or assurances have been made to me regarding the specific outcomes or results of the procedure.

I am fully aware that, in addition to root canal therapy, there are alternative treatment options available, which may include the extraction of the affected tooth or teeth. It is important to note that this list of alternatives is not exhaustive.

I understand and acknowledge that if I choose not to undergo any treatment, my condition may worsen, potentially leading to further infection, cyst formation, swelling, pain, loss of the tooth, and possible systemic disease and infection-related complications

While the primary objective of root canal therapy is to alleviate my condition, I am fully aware that there may be potential complications, which can include, but are not limited to:

- Failure of the procedure, which may necessitate re-treatment, root surgery, or extraction.

- Post-operative pain, swelling, bruising, and/or limited jaw opening that may persist for several days or longer.

- Breakage of an instrument inside the canal during treatment, which may be left in place or require surgical removal.

- Perforation of the canal with instruments, which may require additional surgical treatment or result in the loss of the tooth.

Furthermore, I understand and acknowledge that the successful completion of the root canal procedure does not guarantee immunity against future decay or fractures. An endodontically treated tooth may become more brittle and could potentially change in color. It is generally recommended that a full crown be placed on the treated tooth to minimize the risk of fractures. I also acknowledge that the cost of any additional treatments that may be necessary following the root canal treatment is not included in the price of the root canal treatment itself. Therefore, no refunds will be provided for any treatment costs incurred.

I affirm that I have been provided with ample opportunity to ask questions and have received satisfactory answers to all of my inquiries regarding the recommended treatment, its associated risks, the available alternatives, and the risks associated with those alternatives, including the consequences of choosing not to undergo any treatment.

I understand that as a patient, I have certain rights, including the right to:

- Be fully informed about my condition, treatment options, and associated risks.

- Participate in the decision-making process regarding my treatment plan.

- Seek a second opinion from another qualified healthcare professional.

- Privacy and confidentiality of my medical information in accordance with applicable laws and regulations.

- Receive competent and respectful care from the clinic and its staff.

- Voice any concerns or complaints I may have regarding my treatment or experience.

By signing below, I acknowledge that I have read and understood the above information. I voluntarily consent to undergo the recommended root canal treatment, acknowledging the associated risks and potential complications, as well as the absence of guarantees or assurances regarding the outcomes. I understand and accept the financial responsibility for the root canal treatment and any additional treatments required, and I release the dental clinic, its doctors, and staff from any liability arising from the treatment and its outcomes.

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Doctor name :

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