Informed consent for endodontic retreatment of previous root canal

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Patient name:(Required)

Endodontic retreatment involves, but is not limited to, the removal and treatment of the affected/infected root canal material. Complications from endodontic retreatment may include pain that comes and goes, and swelling which may require medication(s).

Endodontic retreatment may be the only possible treatment option to save your natural tooth. Other treatment choices may include no treatment or tooth extraction.

Risks and infection to other areas:

Although Retreatment has a very high degree of clinical success, results cannot be guaranteed. Occasionally, a tooth that has had root canal therapy may require surgery or even extraction. In some cases, access to the root canals requires drilling through crowns or bridges. This may cause damage to the crown/bridge requiring repair or replacement of your crown or bridge. I also understand that only the root canal therapy is to be performed at this office visit. The restoration on my tooth (filling, crown, etc.) will be done as a separate visit with my dentist. Lack of proper restoration of the tooth may result in damage and/or loss of the tooth.

My treatment options have been explained to me as well as the indications and possible complications of endodontic retreatment and I offer my consent for treatment. Regardless of the outcome, once treatment is initiated the full fee has been incurred whether the case is completed or not due to whatever circumstances of the tooth. The Doctor will use his/her best skill and judgment to try to save the tooth but the outcome cannot be guaranteed.

Before treatment is initiated be certain to have the doctor answer any questions you may have. All signatures must be by a parent or guardian if the patient is under the age of 18.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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