CONSENT FOR ENDODONTIC THERAPY

Endodontic (root canal) therapy is the procedure of cleaning diseased or infected tissue from inside the tooth followed by placement of a seal in the root canal.

Some very infrequent complications include, but are not limited to:

1. Perforations of the tooth or root
2. Damage to axisting restoration.
3. Possibility of a split or fractured tooth.
4. Possibility of separation of a portion of an instrument that cannot be removed from within the tooth.
5. Possibility of pain, swelling, and infection.

Any of these complications could result in failure of the procedure requiring possible retreatment, surgery, or extraction of the tooth.

The alternative to a root canal is extraction. The option of no treatment often results in persistent or recurrent pain and infection in the affected tooth.

Please understand that after root canal treatment, it will be necessary to have a permanent crown done in order to preserve that tooth from cracking.

I have read the above form and have been given the opportunity to ask questions. I authorize my doctor to perform the diagnostic procedures and root canal treatment as outlined above.

Tracy Hill D.D.S.
2211 Midwestern Parkway, St. 5
Wichita Falls, TX 76308
(940) 692-0321
www.netdds.com