Consent Form To Perform Endodontics

This authorization and consent for treatment is given to Dr Neetu Chopra and her staff after first having a full explanation of the proposed treatment. The disclosure in not meant to frighten me. It is simply an effort to make me better informed so I may give or withhold my consent.

The doctor has explained her diagnosis and proposed root canal treatment. The doctor has advised me in her opinion and the consequences of not treating this condition include but are not limited to:

• Worsening of the disease

• Spread of infection

• Cystic formation

• Swelling

• Continuous pain

• Loss of tooth

• And/or other systematic disease manifestations.

The doctor has advised me of alternative treatments, benefits, and risks, which include, are not limited to:

• Extraction of the infected tooth (teeth)

• No treatment

• Referral to a specialist

I, however, believe that the root canal as noted above would be my preferred choice of treatment.

The doctor has advised me that there are certain risks and potential consequences of any treatment and such risks would include but are not limited to:

• A certain percentage (approximately 5-10%) of root canal fails, necessitating re-treatment, root surgery (with a referral to a specialist), or extraction

• Post-operative discomfort, swelling, restricted jaw opening which may persist several days or longer

• Breakage of root canal instrument during treatment which may, in the judgment of the doctor, be left in the treated root canal or require surgery by a specialist for removal.

• Perforation of the root canal with instruments which may require additional surgical corrective treatment by a specialist or result in loss of tooth.

• Premature loss of tooth due to progressive periodontal (gum) disease.

• Root canal treatment relies heavily on radiographic information. Since radiographs are essentially 2-dimesnional shadows which provide reliable but not infallible information, this may lead to root canal failures.

• Successful completion of the root canal procedure does not prevent future decay or fracture. The endodontically treated tooth will be more brittle and may discolor.

• In most cases, a crown and post filling in recommended after completion of the root canal to prevent fracture and/or improve esthetics.

The endodontic fee is given in part of the treatment plan and does not cover alloy, plastic restoration, or crown

I have read and understand the above and had all my questions answered to my satisfaction. I agree to proceed with the recommended root canal therapy.