Healthcare Endodontics Consent Form

HEALTHCARE ENDODONTICS CONSENT FORM

This form documents informed consent for endodontic treatment (including but not limited to root canal therapy, endodontic retreatment, apicoectomy, and related diagnostic procedures). The patient or legal representative confirms receipt of an explanation of the nature of the proposed treatment, alternatives, potential risks and benefits, and agrees to proceed under the terms set forth below.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History

Pregnant or nursing: Yes    Bleeding disorder or on blood thinners: Yes    Cardiac pacemaker or implantable device: Yes

Planned Procedure

Tooth / Teeth to be treated:    Proposed procedure(s):

Appointment Date:

Risks, Benefits and Alternatives

I acknowledge that the provider has explained the nature and purpose of the proposed endodontic procedure, expected benefits, and reasonable alternatives (including no treatment, extraction, or monitoring). I understand that no guarantee of successful outcome has been made.

Common and potential risks include, but are not limited to: persistent or worsening pain, infection, swelling, inability to completely clean root canals, perforation of roots, separation of instruments in the canal, damage to surrounding tissue or adjacent teeth, need for retreatment or apical surgery, numbness or sensory disturbances, sinus involvement for upper teeth, and possible need for extraction. Rare complications can include allergic reaction, systemic infection, or adverse response to medications or anesthesia.

Alternatives to endodontic therapy have been explained and may include extraction with or without replacement by a bridge or implant, or no treatment. Each alternative carries its own risks and benefits.

I confirm that I have had the opportunity to ask questions about risks, benefits, and alternatives and that my questions have been answered to my satisfaction.

I acknowledge the risks, benefits, and alternatives described above.

I consent to local anesthesia and adjunctive medications as necessary (including topical, injectable anesthetics, and routine medications such as analgesics and antibiotics).

I consent to conscious sedation or nitrous oxide if required and explained to me. I understand additional risks specific to sedation were or will be discussed.

Radiographs, Records and Disposition

I authorize the taking of diagnostic images and photographs as necessary. I consent to release of information to my referring dentist and insurance as required for treatment and payment. I understand that removed tissue or debris may be disposed of by the practice unless specifically requested and arrangements are made.

I consent to diagnostic radiographs and photographic records.

HIPAA / Privacy Acknowledgement

I acknowledge that I have been offered or provided with information regarding the practice's privacy policies and my rights with respect to protected health information. I authorize the office to use and disclose my protected health information for treatment, payment, and health care operations.

I acknowledge the HIPAA/privacy notice and authorize use and disclosure as described above.

Authorization and Expiration

By signing below I authorize the performance of the procedure(s) described. I understand I may revoke this authorization at any time prior to the procedure by delivering written notice to the provider, except to the extent that action has already been taken in reliance on this consent.

This authorization will expire on:      

Patient Certification

I certify that I have read and fully understand this consent form, that the information I have provided is accurate to the best of my knowledge, that alternatives and potential complications have been explained to me, and that I consent to the proposed endodontic procedure(s) and related care.

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