ENDODONTIC THERAPY INFORMED CONSENT FORM

I understand that root canal therapy is the treatment performed to retain a tooth which might otherwise require extraction. During root canal therapy, certain procedural complications can occur; including but not limited to separated instruments, blocked canals, root perforations and damage to restorations.

A patient may experience post-operative discomfort and/or swelling and may require medications for several days. Although root canal therapy has a high degree of success, it is still a biological procedure, and as such, cannot be guaranteed. Some teeth that have had root canal therapy may require re-treatment, surgery or even extraction.

I also understand that after the root canal therapy I will need to return to my dentist for a Post or Core-Build-Up and a Full Crown. All teeth that have had a root canal treatment need to be protected by placing a core and a full crown.

When you return to your dentist after the root canal therapy, he/she will remove the cotton that we place over the root canal filling and will replace it with a solid core. This Core-Build-Up needs to be done within 4 to 7 days maximum after completion of the root canal, even if you must wait to get the full crown.

We urge you to place the crown immediately, if you must wait, please do go back to your dentist and remove the cotton that we place over the root canal filling and build up the core. This reduces (but does not eliminate) the chances of breakage and coronal leakage.

This means that there are chances of immediate re-infection of the root canal if it is left unfilled with the temporary filling material over 2 weeks or more. To redo a root canal on the above-mentioned case will be the patient’s responsibility.

I have read and understand the above paragraph that explains why I must return to my dentist for a Post or Core- Build-Up and a Full Crown.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

• Pre and post-treatment instructions have been explained to me.
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
• I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
• Must notify the clinician if my medical history changes prior to subsequent treatments.
• I consent to clinical photographs being taken of my treated areas for my personal health record only.
• There are no refunds for services rendered and/or after a year from purchase and not used.
• The treatments I receive here are voluntary, and I release KAI LIFE CLINIC, my doctors, nurse, and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments.

My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.