Endodontic Procedure Consent Form

I, , hereby authorize Dr. and their staff to perform endodontic (root canal) therapy and any necessary related dental procedures.

Diagnosis and Recommended Treatment

The recommended procedure is:

Potential Risks and Complications

Post-operative discomfort or infection
Instrument separation within the canal
Perforation of root and/or crown
Need for further treatment or surgery
Temporary or permanent numbness
Other:

Alternatives

Extraction of the tooth
No treatment
Other:

Patient Consent

I have read and understand the above information.
My questions have been answered to my satisfaction.
I consent to the recommended endodontic procedure.

Patient Name:	Date:
Patient Signature:	Doctor/Witness: