Ballard Family Dentistry
1703 NW Market Street
Seattle, WA 98107
INFORMED CONSENT FOR ROOT CANAL TREATMENT
(Patient's name)
(tooth
I understand that root canal treatment is an attempt to save a tooth due to loss of vitality
from infection, trauma, decay, or in restorative procedures, to attain sufficient retention or
contour for a new crown. •Ille procedure and its alternatives have been explained to me
and I have been informed that occasionally there are complications concerning this
treatment.
Possible risks and complications of this treatment include allergic reactions to
medications or anesthetics, pain, swelling, and sensitivity to pressure or Other discomfort
during or aner the root canal is sealed. Treatment may be modified or discontinued due
to calcified canals, inaccessible canals, fracture of the roots or crown Of the tooth,
perforation, resorption, or instruments separated in the root
I understand that in a few cases a surgical procedure may be indicated to seal othenvise
inaccessible canals or to remove the infected apical portion of the root canal treatment.
The natural crown of the tooth may darken eventually and/or become brittle and may
even fracture following the root canal treatment. Therefore, I understand the importance
of having the tooth restored as soon as possible With a crown or a permanent filling.
Alternatives to root canal treatment are extraction of the tooth or no treatment. A root
canal infection, left untreated, may cause serious symptomatic infection, which may
endanger my health.
The dental care and treatment to be perforrned has been fully explained to me and I
understand What is to be done. I have received a detailed explanation Of all risks, benefits
ofand alternatives to the treatment. I have asked and received answers to all the
questions I had regarding this treatment _ I understand What is to be done and that there is
no warranty Of guarantee as to any result and /or cure. Also, I understand that any
necessary follow-up treatment cost (s) for complications resulting from root canal
treatment are the responsibility Of the patient.
I have read and understand the terms and conditions Of treatment _ I consent to the root
canal treatment, including the use Of local or Other anesthetics, and needed x-rays.
Patient's pf Authorized Signature
Witness's Signature
Date
slidesharecdn.com