Tooth/teeth number(s) :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 the medical and dental procedures, It is a procedure whose results cannot be guaranteed. Root canal treatment is performed to correct an apparent problem. This procedure will not prevent future tooth decay, tooth fracture, or gum disease. Occasionally, a tooth that has had a root canal treatment may require treatment, endodontic surgery, or tooth extraction.I understand that non treatment may result in, but it's not limited to: Increased risk of complications if delayed infection and/ or abscess Pain and/ or swelling Need for immediate emergency treatment if symptoms worsen I understand that there are risks associated with any dental, surgical, and anesthetic procedure. These risks 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 Medical problems may occur, If I do not have the root canal completed Reactions to anesthetics, chemicals or medication By signing, I understand the recommended treatment, the fee involved, and the risks of such treatment, any alternatives and risks of the alternatives. I understand the information discussed and have had the opportunity to ask any questions. Patient NameDatePatient/Parent/Guardian Signature Dentist Signature SendThis field should be left blank
