Healthcare Patient Root Canal Consent Form

Healthcare Patient Root Canal Consent Form

Patient Information

Date of Birth:    Gender: Male Female Other/Prefer not to state

Insurance Information

Medical History

Do you have a heart murmur, artificial joint, or a condition requiring antibiotics prior to dental procedures? Yes

Are you pregnant or breastfeeding? Yes

Proposed Procedure

Planned Procedure Date:

Anesthesia, Sedation and Medications

I consent to administration of local anesthetic agents and adjunct medications as necessary. I understand the clinician will determine anesthesia appropriate to my care.

Local anesthetic (e.g., lidocaine)    Intraligamentary/field block

Nitrous oxide    IV or moderate sedation (if indicated)

I acknowledge I have disclosed allergies to anesthetics or medications:

Risks, Complications and Possible Adverse Outcomes

The nature and purpose of root canal therapy have been explained to me. The following risks, complications, and possible adverse outcomes have been explained and I acknowledge understanding each item below:

Persistent or increased pain despite therapy

Continued or new infection requiring additional treatment or extraction

Swelling, bruising, or bleeding

Numbness, paresthesia, or altered sensation of lip, tongue or skin (may be temporary or permanent)

Sinus involvement or communication (upper teeth)

Fracture of tooth structure or root that may require extraction

Allergic reaction to medications or materials used

Failure of the procedure to resolve symptoms, necessitating further treatment or referral

Alternatives to Proposed Treatment

Alternatives explained to me (select all discussed):

No treatment (risk of progression of infection/pain)

Extraction of the affected tooth with or without replacement (implant/bridge)

Observation and symptomatic therapy / antibiotics and follow-up

Radiographs, Photographs and Records

I authorize necessary radiographs, intraoral or extraoral photography, and clinical records for diagnosis and treatment documentation. I understand such records are part of my medical chart.

I consent to radiographs, photographs, and use of records for treatment purposes.

HIPAA & Privacy Acknowledgment

I acknowledge that I have been offered or received a copy of the clinic's privacy practices and that I have been informed of how my protected health information may be used or disclosed.

I acknowledge receipt of the privacy practices notice.

Authorization Expiration and Additional Requests

This authorization shall expire on:

Patient Certification and Consent

I certify that I have read (or the clinician has read to me) the contents of this consent form. I have had the procedure, risks, benefits, alternatives, and possible complications explained to my satisfaction. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand that no guarantee or assurance has been made to me concerning the results of the procedure. By signing below I consent to the performance of the root canal therapy and associated procedures as deemed necessary by the treating clinician.

Patient Initials:

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