Root Canal Specialist - Endodontics Newport News VA ...



Root Canal SpecialistsCONSENT FOR ENDODONTIC THERAPYPlease review the following consent form. You will be required to sign this form prior to the initiation of treatment. Your signature does not commit you to any treatment.I understand that root canal therapy is a procedure that retains a tooth, which may otherwise require extraction. As a specialty practice, this office performs only endodontic therapy and associated surgery. Although root canal therapy has a very high degree of success, results cannot be guaranteed. Occasionally, a tooth, which has had root canal therapy, may require retreatment, surgery, or even extraction. Following treatment, the tooth may be brittle and subject to fracture. A restoration (filling), crown and/or post and core will be necessary to restore the tooth, and your general dentist will perform these procedures. During endodontic treatment, there is the possibility of instrument separation within the root canals, perforations (extra openings), damage to bridges, existing fillings, crowns or porcelain veneers, missed canals, loss of tooth structure in gaining access to canals, and fractured teeth. Also, there are times when a minor surgical procedure may be indicated or when the tooth may not be amenable to endodontic treatment at all. Other treatment choices include no treatment, a waiting period for more definitive symptoms to develop, or tooth extraction. Risks involved in those choices might include, but are not limited to, pain, infection, swelling, loss of teeth, and infection to other areas.Proper post-treatment restoration for the treated tooth is necessary. Please contact your dentist soon after the completion of treatment for restoration of the tooth. Possible unavoidable complications of endodontic therapy include but are not limited to: Swelling, soreness, muscle spasms, fracture of the crown or root of the tooth, separation of root canal instruments during treatment, blocked canals due to filling, natural calcification, severely curved roots, root resorption, perforation of the root especially in case of severe calcification, damage to existing crowns, bridges, adverse reactions to anesthetics and medications administered and prescribed for treatment. During treatment complications may be discovered which make treatment impossible or which may require dental surgery or extraction of the tooth. All of my questions have been answered by Root Canal Specialists and I fully understand the above statements in this consent form.If I am prescribed an opioid after treatment, I understand and give permission for Root Canal Specialists to run an Opioid Awareness check on my prescription history to evaluate my risk score for abuse or overdose. This is done online through PMP Aware at no cost. Furthermore, I give Root Canal Specialists my permission to voice record, tape digitally, videotape and/or take 35mm and/or digital photos of my procedure for purposes of completing my medical record and/or for patient education. Note: All medical records will be kept strictly confidential.Patient (Print Name)________________________________Patient (Signature)________________________________Date________________________________(If patient is under the age of 18, the signature of a parent or guardian is required.)Root Canal SpecialistsAdditional Informed ConsentPatients with crown, bridge, onlays or inlaysAs careful as we are during root canal therapy, there is always the possibility that the crown, bridge onlay or inlay can be damaged during or after root canal therapy has been rendered. Normally, root canal therapy can be successfully done through a crown, bridge, onlay or inlay without any problems. This is true 95% of the time. However, because we do not know what the status of the natural tooth structure is, the position the crown is in (relative to natural tooth structure), the potential for decay or fractures or the thickness of porcelain, there is a possibility that the crown, bridge onlay or inlay can become damaged during or after treatment. This means the porcelain/gold/natural tooth can be cracked, chipped, broken or dislodged at any time during and/or after root canal therapy. Every precaution is taken to prevent damage.In addition, if necessary, it is possible that the crown, bridge, onlay or inlay may need to be intentionally removed in order to facilitate proper root canal therapy. This becomes more likely if there is decay, fractures, or calcified canals. As your healthcare provider, I am directly informing you that should any damage occur to the crown, bridge, onlay or inlay, you-the-patient, accept full responsibility for fabrication of the restoration. It is not our responsibility to fabricate or pay to fabricate a new restoration. I fully understand the potential for damage and accept all responsibility replacing the restoration should the situation rise. ____________________________________________________ ________________Patient SignatureDate ................
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