Root Canal Treatment Consent Form

First Name*

Last Name*

Date of Birth

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I understand and agree to the planned treatment. I consent to the following tooth/teeth to be have root canal treatment * I understand and agree to the planned treatment. I consent to the following tooth/teeth to be have root canal treatment * Agree Disagree

Please nominate which tooth/teeth are to be extracted *

The method and manner of the proposed treatment have been explained to me. I have been explained and understand the alternatives to root canal treatment. * The method and manner of the proposed treatment have been explained to me. I have been explained and understand the alternatives to root canal treatment. * Agree Disagree

I consent to the administration of local anaesthesia for this procedure and have informed my Dentist of any reactions I have had to adrenalin in the past. * I consent to the administration of local anaesthesia for this procedure and have informed my Dentist of any reactions I have had to adrenalin in the past. * Agree Disagree

I have been informed of possible risks and complications which include, but are not limited to: Post treatment discomfort lasting a few hours to several days for which medication may be prescribed if necessary. Post treatment swelling of the gum in the vicinity of the tooth, or facial swelling, either of which may persist for several days or longer. Infection. Trismus (restriction of jaw opening) which usually lasts several days but may last longer. Failure of the root canal (failure rate of 5% - 10%). If failure occurs the treatment may have to be redone, root end surgery may be required or the tooth may have to be extracted. Breakage of root canal instruments during treatment, which may, at the best judgement of the Dentist, be left in the treated root or require surgery for removal. Perforation of the root canal with instruments that may require additional corrective surgical treatment or result in tooth extraction. Premature tooth loss due to progressive periodontal (gum) disease in the surrounding areas. * I have been informed of possible risks and complications which include, but are not limited to: Post treatment discomfort lasting a few hours to several days for which medication may be prescribed if necessary. Post treatment swelling of the gum in the vicinity of the tooth, or facial swelling, either of which may persist for several days or longer. Infection. Trismus (restriction of jaw opening) which usually lasts several days but may last longer. Failure of the root canal (failure rate of 5% - 10%). If failure occurs the treatment may have to be redone, root end surgery may be required or the tooth may have to be extracted. Breakage of root canal instruments during treatment, which may, at the best judgement of the Dentist, be left in the treated root or require surgery for removal. Perforation of the root canal with instruments that may require additional corrective surgical treatment or result in tooth extraction. Premature tooth loss due to progressive periodontal (gum) disease in the surrounding areas. * Agree Disagree

I accept and understand that the tooth is weakened following root canal therapy and may require a crown (cap) in future to strengthen and protect the tooth. * I accept and understand that the tooth is weakened following root canal therapy and may require a crown (cap) in future to strengthen and protect the tooth. * Agree Disagree

I accept and understand that long-term post-operative monitoring including radiographs are required and cooperation in keeping scheduled appointments is important. Regular dental check-ups with your Dentist are important to monitor and attempt to prevent break down in your oral health. * I accept and understand that long-term post-operative monitoring including radiographs are required and cooperation in keeping scheduled appointments is important. Regular dental check-ups with your Dentist are important to monitor and attempt to prevent break down in your oral health. * Agree Disagree

I realise that, despite all precautions that may be taken to avoid complications, there can be no guarantee as to the result of the proposed treatment. * I realise that, despite all precautions that may be taken to avoid complications, there can be no guarantee as to the result of the proposed treatment. * Agree Disagree

I accept the estimation of the fees as provided and agree to pay the final fee on the date of service or prior. * I accept the estimation of the fees as provided and agree to pay the final fee on the date of service or prior. * Agree Disagree

I certify that I speak, read and write English and have had my questions answered. I have read and fully understand this consent for surgery. * I certify that I speak, read and write English and have had my questions answered. I have read and fully understand this consent for surgery. * Agree Disagree