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HOME
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5-Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
SERVICES
Emergency Services
Emergency Dental Exams
Dental X-Rays
Cuts & Lacerations
Dental Root Canal
Dental Filling Cavities
Crowns & Bridges
Repair Broken Teeth, Fillings, Crowns & Dentures
Replacement Of Fillings & Crowns
Removal Of Foreign Bodies
Treatment Complications
Cleaning and Prevention
Complicated Tooth Extractions
Dental Restorations
Cosmetic Dentistry
Periodontal Disease
FOR STUDENTS
BLOG
News
SERVICE AREAS
Waterloo
Beechwood Waterloo Ontario
Beechwood West-Ontario
Clair Hills-Ontario
Colonial Acres-Ontario
Upper Beechwood-Ontario
View All Areas
Book An Appointment
Endodontic (Root Canal) Therapy Informed Consent
Endodontic (Root Canal) Therapy Informed Consent
Waterloo Emergency Dental Centre
258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505
Prior to undergoing Root Canal Therapy it is important that you read, understand and consent to the following:
The alternative to Root Canal Therapy is usually Extraction
The completed treatment usually takes between 1-3 visits
There is a 5-10% chance that the root canal therapy may not work. Further dental treatment may be necessary in such cases.
The treatment is generally painless but some discomfort may occur between visits which can be controlled pharmaceutically
Existing restorations, crowns, veneers or tooth structure may break as a result of root canal therapy
Instruments used to clean the tooth may break and/or perforate the internal part of the tooth
Complications may be encountered due to difficult tooth anatomy, blocked canals, preexisting treatment, split tooth, breakage of instruments inside tooth or perforations of the tooth.
Such complications may result in the necessity to extract the tooth, perform further dental treatment such as apical surgery and/or referral to endodontic specialist to complete the necessary treatment
Crown with or without post/core is strongly recommended to reduce the chance of fracture of the root canal treated tooth
The treatment has been discussed with my dentist and any additional questions and concerns have been addressed
Consent
*
I HAVE READ AND UNDESTAND THE ABOVE INFORMATION AND WISH TO PROCEED WITH THE ROOT CANAL THERAPY ON TOOTH
Patient’s Name
*
.
Tooth No (s)
*
Please enter a number(s) from 1 to 48.
Date
*
.
DD slash MM slash YYYY
Patient’s Signature
*
(Write Your Name)
Dentist/Treatment Coordinator
*
(Write Your Name)
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