Root Canal Consent From

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ROOT CANAL TREATMENT CONSENT FORM

Patient Name: ____________________________
Date of Birth: ____________________________
Dentist’s Name: ____________________________
Date of Procedure: ____________________________

Introduction

Root canal treatment is a procedure used to save a tooth that has been severely decayed or infected. The treatment involves removing the infected pulp, cleaning the root canals, and sealing them to prevent further infection.

Procedure Explanation

I understand that:

A local anesthetic will be used to numb the area.
The infected or damaged pulp will be removed from the tooth.
The root canals will be cleaned, shaped, and filled.
A temporary or permanent filling/crown may be placed.
Additional appointments may be needed.

Risks and Complications

I understand that potential risks include, but are not limited to:

Pain, swelling, or discomfort after the procedure.
Temporary or permanent numbness in the treated area.
Possible failure of the procedure, requiring retreatment or extraction.
Cracking or fracture of the tooth, possibly requiring further treatment.
Reaction to anesthesia or medications.

Alternative Treatment Options

I have been informed of the alternatives to root canal therapy, which may include:

Tooth extraction.
No treatment, understanding that the infection may worsen.

Post-Treatment Care

I understand that:

I must follow the dentist’s post-treatment instructions.
A permanent restoration (such as a crown) may be necessary to protect the tooth.
I should contact the dental office if I experience severe pain, swelling, or any unusual symptoms.

Consent & Acknowledgment

I have had the opportunity to ask questions and fully understand the procedure, risks, and alternatives. I consent to the root canal treatment as recommended by my dentist.

Patient’s Signature: ____________________________
Date: ____________________________

Dentist’s Signature: ____________________________
Date: ____________________________

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