Information And Consent For Endodontic (Root Canal) Treatment
- I authorize Dr. Blake , to treat the condition(s) described below. This condition (s) has been explained to me, and I understand the nature of the procedure (s) to be:
- I understand that there are certain inherent and potential risks in any treatment plan or procedure, and that in this specific instance such risks include but not limited to, the following:
- Post-operative discomfort and swelling that may necessitate several days of home recuperation.
- Post-operative infection, requiring additional treatment.
- Failure to resolve the abscess, or worsening of the abscess.
- Perforation of the root or crown of the tooth, which may be repaired, or may necessitate extraction of the tooth.
- Separation of a file in the root of the tooth. The separated segment may be removed, or left in place and incorporates into the root canal filling.
- Inability to instrument and fill root canal(s) completely to the root tip(s).
- I understand that during the procedure(s), unforeseen conditions may be revealed which may necessitate a change in treatment plan, in which case the dentist will explain to me the change and the reason for it.
- I understand that not treating this condition could cause problems, including, but not limited to: worsening of the abscess; sinus, jaw, or facial infections; loss of tooth or teeth.
- I understand that successful endodontic treatment requires conscientious plaque removal by the patient (brushing, flossing, and other procedures recommended by the dentist), periodic recall visits for observation, and the restoration of the tooth with a crown.
- Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness or coordination, which can be increased by alcohol or other drugs; thus, I have been advised not to operate any vehicle, automobile, or hazardous devices, or work, while taking such medications and /or drugs; or until fully recovered from the effects of same.
- I understand that a perfect result is not guaranteed or warranted, and cannot be guaranteed or warranted.
- I certify that I have read and fully understand this consent for endodontic treatment, or that it was translated for me, and that all blanks or statements requiring insertion or completion were filled in, and that "NA" was written beside all statements which were not applicable to my treatment before I signed.
PLEASE ASK THE DENTIST IF YOU HAVE ANY QUESTIONS CONCERNING THIS CONSENT FORM.
Monday 8:00 am - 5:30 pm
Tuesday 8:00 am - 5:30 pm
Wednesday 8:00 am - 5:30 pm
Thursday 8:00 am - 5:30 pm
507 Dwight Street, Coudersport, PA 16915