Non-Surgical Endodontic Therapy Informed Consent printable pdf download

NON-SURGICAL ENDODONTIC THERAPY INFORMED CONSENT

I understand that root canal therapy is a treatment performed to retain a tooth which might otherwise

require extraction. During root canal therapy, certain procedural complications can occur including, but not

limited to, alteration of sensation, i.e., numbness, separated instruments, blocked canals, root perforations,

and damage to restorations. A patient may experience post operative discomfort or swelling and may

require medications for several days. 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 treatment, surgery, or even extraction. Further, in my particular case, I have been informed that the

prognosis for my tooth #_____is not good, and therefore it is quite possible that in spite of all treatment

attempted to retain the tooth it will be necessary to extract it. Nevertheless I have chosen to undergo

endodontic treatment and accept full financial responsibility for the treatment regardless of the outcome.

I understand that only root canal therapy will be performed in this office. A subsequent restoration (filling,

crown, onlay, etc.) will be needed and will be performed by my general dentist.

PATIENTS WITHOUT DENTAL INSURANCE

I understand that I am responsible for payment of the fees for services rendered.

PATIENTS WITH DENTAL INSURANCF:

When treatment is started the staff will be asking me for a patient initial payment along with an insurance

claim form which I must have filled out completely and accurately, assigning benefits to the attending

dentist. The staff will then complete the dental portion and forward the claim to the insurance company on

the day mv root canal therapv is completed. After payment has been received from the insurance company,

I will either receive a bill for any remaining balance or a refund check if the insurance company has paid

more than anticipated.

Tooth Treated__________________________

Patient Initial Payment ______________________Fee__________________________

Signed By______________________________________Date_____________________

patient, parent, guardian (please circle)

Signed By_______________________________________Date_______________________

Doctor

Signed By_______________________________________Date_________________________

Witness

Non-Surgical Endodontic Therapy Informed Consent