Consent for endodontic treatment and / or surgery

Download 31 Kb.
Size31 Kb.
PLEASE NOTE: The doctor will review your treatment needs and answer any and all questions you may have prior to initiating treatment. The appropriate condition and treatment will be check-marked at that time.

  • I, ________________________________ (print name) hereby authorize Dr. Saidon, with the help of any assistant selected, to treat the condition(s) described below:

___ Pulpal inflammation / degeneration ___ Tooth / root fracture ___ Tooth discoloration
___ Failure of previous endodontic treatment ___ other: _________________________

  • The procedure(s) necessary to treat the condition(s) have been explained to me, and I understand the nature of the procedure(s) to be:

___ Root canal treatment ___ Root canal retreatment ___ bleaching
___ Endodontic surgery ___ other: ________________________

  • I have been informed that a local anesthetic (“novocaine”) and radiographs (‘X-rays) will be used.

  • I have been informed of the prognosis and the benefits of these procedures. I have been informed of possible alternative methods of treatment, including no treatment at all.

  • I am aware there are certain inherent and potential risks in any treatment plan or procedure. I understand that these risks for the treatment I will receive include, but are not limited to: Swelling; sensitivity; bleeding; pain; infection; numbness and/or a tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth, which is transient but on infrequent occasions may be permanent; reaction to injections and anesthetics; changes in occlusion (biting); jaw muscle cramps and spasms; temporomandibular joint difficulty; referred pain to ear, neck and head; delayed healing; sinus communication; complications resulting from the use of dental instruments (broken instrument, perforation of the root); bruising of the face; tooth discoloration; loosening of teeth; loosening or fracture of crowns or bridges requiring the fabrication of new ones; reactions to medications which may include drowsiness and lack of coordination; Allergic reactions to any materials and medications used; inhibition of the effect of birth control pills (if taking antibiotics); treatment failure.

  • I understand that when this treatment is completed, I will need to see my general dentist within the following few weeks for continued treatment which will include a permanent restoration (post and core / buildup / Crown / bridge / filling), crown lengthening surgery (when indicated), and routine dental care.

  • For patients who are currently receiving Bisphosphonate treatment or have in the past – I was informed of the short and long-term risks associated with my drug treatment.

  • I was given the opportunity to ask any questions and bring up any concerns regarding the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment.

  • I was given ample time to read this consent form. I have read this consent form and voluntarily consent to the performance of the above procedure(s) upon me.

Patient signature __________________________________________________ Date ________________

Parent/Guardian signature ___________________________________________ Date _______________(if patient is a minor)
Witness signature __________________________________________________ Date _______________

Please turn the page over.

Share with your friends:

The database is protected by copyright © 2019
send message

    Main page