Informed Consent for Dental Treatment

Patient name: ________________________________ Date: ______________ Tooth/Teeth #:_________1. The purpose of root canal therapy is to retain teeth that would otherwise have to be extracted.2. Treatment may require multiple visits. It is important that you maintain scheduled appointments or the infection can reoccur.3. In most case, there is only mild discomfort following each treatment. This is usually controlled with aspirin. Tylenol, ibuprofen or prescribed medication.4. Endodontic treatment has a high degree of success. As in any medical or dental treatment, however, this treatment has no guarantee of success for any length of time. Teeth with previous root canal treatment that require re-treatment will have a lower success rate.5.5. Accurate and complete disclosure of medical information is necessary for proper diagnosis, and to help prevent unnecessary complications during your treatment.6. The most common complications with root canal therapy include, but not are limited to:

A. Prolonged numbness (paresthesia) as a normal risk of local anesthetic administration. B. Acute infection (flare up) between visits or immediately after completion of treatment which may require further management. C. Calcified canals or canals blocked by broken instruments requiring root canal surgery or tooth extraction. D. Instrument separation (breakage) resulting in retention of a small fragment within the canal system. Prognosis is typically unaffected. In the case of file separation, there is risk of perforation. E. Pain, requiring the use of medications. F. Side effects and reactions to medication. G. Fractures (breaking) of the root or crown of the tooth during or after treatment. It is recommended that all teeth be restored following root canal treatment. If your tooth already has a crown, there is a chance it will need to be replaced due to decay or loss of structural support. Porcelain crowns are subject to breakage. Any crown might come off during or after treatment. H. Tenderness of the tooth following treatment due to possible complications with root canal treatment, gum disease, physical stress from chewing, or the degree of healing your body exhibits. I. Continued infection requiring endodontic (root canal) surgery or extraction of the tooth. J. Jaw muscle stiffness, transient limited opening and/or TMJ involvement may occur following root canal therapy. The condition usually passes without treatment. Occasionally, the condition requires treatment by a specialist.

7. Other treatment choices include no treatment, waiting for more definite development of symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, malocclusion, and infection to other areas. in these choices might include pain, infection, swelling, loss of teeth, malocclusion, and infection to other areas. 8. This consent form does not encompass the entire discussion I had with the doctor regarding the proposed treatment.9. Your referring dentist will advise you on the restorative phases of treatment and the financial investment involved.10. It is the patient’s responsibility to contact this office for the recommended follow up.11. To help insure success of the root canal therapy, I understand that I am responsible for returning to my General Dentist for final restoration of the tooth as soon as possible after completion of root canal therap restoration of the tooth as soon as possible after completion of root canal therapy. I understand that no more than 4-6 weeks should elapse before final restoration.12. In the event re-treatment or surgery becomes necessary, additional fees may apply.13. The procedure(s) necessary to treat the condition(s) have been explained to me and I understand the nature of the procedure to be Endodontic (root canal) treatment. I have been given the opportunity to ask questions.14. I understand that it is my responsibility to contact the office should there be any complications with my treatment, including but not limited to swelling, pain, numbness, or bruising.15.15. The risks and benefits of root canal therapy and other treatment options (ie. tooth extraction) have been fully explained to me.16. I understand that, if I choose to be sedated for my treatment, I will need a driver to and from my appointment. Initial: _______

“I have read and understand the above, and hereby consent to treatment” Refusal of recommended treatment.

__________________________________________________ __________________________________________________Patient Signature Witness

Treatment Plan_____ Clinical Exam ................................................._________

_____ Radiographs .................................................._________

_____ Non-surgical Root Canal Treatment..............._________

_____ Retreatment .................................................._________

_____ Incomplete Endo............................................_________

__________ Removal of Root Canal Obstruction..............._________

_____ Incision & Drainage........................................ _________

_____ Filling/Core Buildup........................................._________

_____ Post removal/Retrieval..................................._________

_____ Non-vital Bleaching........................................_________

_____ Apexification/Apexogenesis (per visit)............_________

_____ N2O (laughing gas)........................................_________

__________ Oral Pre-Med Monitoring (Driver Needed)....._________

_____ Apicoectomy Surgery...................................._________

_____ Retrograde Filling..........................................._________

_____ Biopsy............................................................_________

_____ Pulpal Regeneration......................................_________

ESTIMATED Total....................................................._________

ESTIMATED Patient Total for exam + xray..............._________

ESTIMESTIMATED Patient Total for Treatment.................._________

ESTIMATED Patient responsibility shouldinsurance not pay within 30 days........................._________

*** Our patients are responsible for any copay, deductible andbalance due on the day of service. Any services performed will befiled to your insurance. The patient is responbile for any balance notcovered by insurance or paid by insurance after 30 days. Initial: _________

*** WE ACCEPT CASH, CHECK, MAJOR CREDIT CARDS AND CARECREDIT (Monthly Payment @ 0% Interest for 6 months)

*** $40 FEE FOR RETURNED CHECKS

*** FEE ESTIMATE HONORED FOR 60 DAYS. FEES ARE HONORED IF TREATMENT IS COMPLETED ON SCHEDULED APPOINTMENTS.

Dr. Haris Iqbal, DDS, MSD