Informed Consent for Endodontic Treatment

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

Informed Consent for Endodontic Treatment

The goal of root canal treatment is to save a tooth that might otherwise require extraction. Although root canal treatment has a very high success rate, as with all medical and dental procedures, it is a procedure whose results cannot be guaranteed. This procedure will not prevent future tooth decay, tooth fracture or gum disease, and occasionally a tooth that has had root canal treatment may require re-treatment, endodontic surgery, or tooth extraction.

Risks: Are unlikely but may occur. They might include but are not limited to: Instrument separation in the canal. Perforations (extra openings) of the canal with instruments. Blocked root canals that cannot be ideally completed. Incomplete healing. Post-operative infection requiring additional treatment or the use of antibiotics. Tooth and/or root fracture that may require extraction. Fracture, chipping, or loosening of existing tooth or crown. Post-treatment discomfort. Temporary or permanent numbness. Change in the bite or jaw joint difficulty (TMJ problems or TMD).

Other Treatment Choices: No treatment at all. Extraction: To be replaced with either nothing, a denture, a bridge or an implant Referral to endodontist

After the completion of the root canal procedure, a crown is typically recommended. Failure to have the tooth properly restored in a timely manner (generally within 30 days) significantly increases the possibility of failure of the root canal procedure or tooth fracture. I have had an opportunity to ask questions of my treating doctor and I am satisfied with the answers that I have received. I consent to the procedure.

Tooth #:

Patient First Name

Patient Last Name

Patient Signature

Dentist Signature:

Date / Time

Phone

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

Have A Question? Call Us

Book An Appointment

Quick Links

Home
About Us
Services
Patient Forms
Medical History Form
Contact Us
Privacy Policy

Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed