Your Contact Information

First Name:
Last Name:
Email Address:
Treatment Location:

Consent for Endodontic Evaluation

I understand my tooth will be evaluated for possible endodontic treatment.

Consent for Endodontic / Emergency Treatment

SHOULD ENDODONTIC TREATMENT BE APPROPRIATE, PLEASE READ BELOW.

I understand that the root canal therapy is a treatment performed to retain a tooth which might otherwise require extraction. I have been informed of possible alternative methods of treatment including no treatment at all.

During root canal therapy, certain procedural complications can occur including but not limited to, i.e., numbness, separated (broken) instruments, blocked canals, root perforations, alteration of sensation, and damage to restorations.

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 understand that only the root canal treatment is to be performed at this office and that my restorative dentist will do the follow up treatment (filling, crown, etc.).

I understand that the dentists performing the endodontic treatment are specialists in this field.