We would like our patients to be informed about the various procedures involved in endodontictherapy and have their consent before starting treatment. Endodontic (root canal) therapy isperformed in order to save a tooth which otherwise might need to be removed. This isaccomplished by conservative root canal therapy, or when needed, endodontic surgery. Treatmentwill require a series of x-rays and may require multiple visits. It is important you keep scheduledappointments, or infection may reoccur. The following discusses possible risks that may occur fromendodontic treatment, and other treatment-choices.

RISKS: The risks include, but are not limited to, the possibility of instruments broken within the rootcanals, perforations (extra openings) of the crown or root of the tooth; damage to bridges, existingfillings, crowns, or porcelain veneers; loss of tooth structure in gaining access to canals; and crackedteeth. (Numbness of the lip, chin, cheek, or teeth may occur). During treatment, complications maybe discovered which make treatment impossible, or which may require dental surgery. Thesecomplications may include: blocked canals due to fillings or prior treatment, natural calcifications,broken instruments, curved roots, periodontal disease (gum disease), or slips or fractures of theteeth.

MEDICATIONS: Medications that are sometimes prescribed for pain may cause drowsiness and lossof coordination (which may be influenced by the use of alcohol, tranquilizers, sedatives, or otherdrugs). It is not advisable to operate any vehicle or hazardous device until recovered from theireffects. Antibiotics, if prescribed, may temporarily lessen the effectiveness of birth control pills.

OTHER TREATMENT CHOICES: These include no treatment (waiting for more definite developmentof symptoms) or tooth extraction. Risks involved in these choices might include pain, infection,swelling, loss of teeth, and infection to other areas.

CONSENT: I, the undersigned, being the patient (parent or guardian of minor patient), consent tothe performing of procedures decided upon to be necessary or advisable in the opinion of thedoctor. I also understand that upon completion of root canal therapy in this office I will return tomy general family dentist for a permanent restoration of the tooth involved, such as crown, cap, orother permanent filling.

I understand that root canal treatment is an attempt to save a tooth which may otherwise requireextraction. Although root canal therapy has a high degree of success; there is no guarantee ofsuccess for any length of time. Occasionally a tooth which has had root canal therapy may require aretreatment, surgery, or even extraction.

I give this practice / clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
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I have been informed that I may review the practice / clinic's Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent.
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I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice / clinic.
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I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice / clinic is not required to agree to the request. If the practice / clinic agrees to my requested restriction they must follow the restriction(s).
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I also understand that I may revoke this consent at any time, by mailing a request in writing, except for information already used or disclosed.