I completely understand that I have been advised that I require root canal treatment. I understand the purpose of endodontic or root canal treatment is an attempt to save a tooth rather than remove it. I understand the desirability of root canal treatment compared to extraction and the consequences of not having root canal treatment.
I understand root canal therapy removes the source of the infection from the tooth. Once the source of the infection has been removed, the body will usually heal the infected tissue directly adjacent to the tooth. If the body does not heal the infected tissue, the infection may persist. Root-end surgery may be required, or the tooth may have to be removed.
Treatment may require multiple visits. It is important that scheduled appointments be maintained or the infection can reoccur. After root canal treatment, I understand that I will need to return to my general dentist for permanent restoration of the tooth.
Dentistry is not exact science and overall endodontic treatment has a high degree of success. As any medical or dental treatment, however, this treatment has no guarantee of success for any length of time. Occasionally, the tooth that has had root canal treatment may require retreatment, root-end surgery, crown after the filling to make sure filling doesn’t break due to heavy biting forces.
I fully understand the statements (risks, benefits, alternatives) in this consent form and I have been given a chance to ask all the questions and their answers before. I also understand that medications, drugs, anesthetics and prescriptions that may be required during the treatment may cause some adverse or unanticipated reactions, which may require medical attention. I also understand I should not consumed alcohol or any other drug at the same time because they van increase these effects.
Unforeseen conditions may arise that require a procedure that is different that set forth above. In light of this information, I hereby authorize my dentist or th to proceed with root canal treatment.
Thank you for entrusting your dental treatment to Derry Village Dental Care. It is an honor for us to have been selected by you to do so. Our service philosophy is to be informed, honest, and fair. This Financial Agreement demonstrates our appreciation for your right to know ahead of time what our financial expectations are. Please contact our office of you have any questions or issues regarding our Financial Agreement.
We will happily submit your claims and accept assignment of dental insurance coverage as a favor if you agree to the following: