Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

PATIENT INFORMATION AND
CONSENT FOR ROOT CANAL TREATMENT

Patient's Name
DOB
Date
Phone
Email
Planned diagnostic procedure for tooth/teeth : #
Referring Dentist :
Diagnosis:
Planned treatment :
Restoration placed:
Date completed:
Restoration recommended:

(Above for office use ONLY)

What is root canal treatment and what are its benefits?

Root canal treatment is the procedure of cleaning diseased or infected tissue from inside the tooth followed by placement of a seal in the root canal. Using a local anesthetic, there is minimal or no discomfort during the procedure. Root canal treatment allows the tooth to remain in the mouth and contributes to sound, healthy, and functional dentition for many years, if not a lifetime. The practice of endodontics also includes such procedures as bleaching, inducing closure of immature diseased root, treatment of traumatic injuries, and the fabrication of posts and buildups under crowns.

What are the complications of treatment?

With a success rate of approximately 95%, endodontic therapy is one of the most reliable dental or medical procedures, and complications are not expected. However, there can be no absolute guarantee regarding treatment success. Some very infrequent complications include, but are not limited to: the possibility of perforations of the tooth or root, damage to existing restorations (fillings, onlays, crowns and/or bridges), the possibility of a split or fractured tooth, the possibility of separation of a portion of an instrument that cannot be removed from within the tooth, and the possibility of pain, swelling, and infection. The use of prescription drugs during treatment may also result in unexpected drug reactions. Any of these complications could result in failure of the procedure requiring possible re-treatment, periapical surgery or extraction of the tooth.

What alternatives do you have?

Extraction of the tooth is an alternative. If the tooth is removed and not replaced, the empty space will create problems in tooth alignment because of shifting of adjacent teeth. This may result in periodontal (gum) disease, and you could lose more teeth as a consequence. The missing tooth may be replaced by a bridge or partial denture, but the cost for this is often more expensive than root canal treatment and involves dental work on adjacent teeth. The option of no treatment often results in persistent or recurrent pain and infection in the affected tooth. If any doubt exists in your mind about treatment, we encourage you to seek a second opinion

What are your responsibilities?

It is important to provide a complete and accurate medical history. Following completion of endodontic root canal treatment, fracture and loss of the root canal-filled tooth due to brittleness may be more likely to occur unless the root canal-filled tooth is restored with a crown within a month. A crown (if needed) is a separate procedure from the root canal treatment and a separate fee will be charged by your dentist . Depending upon your situation, certain other post-treatment precautions or special instructions must be followed (such instructions will be given to you separately by the doctor or other staff member).

I have read the above form and have been given the opportunity to ask questions. I acknowledge my responsibility to pay the fees involved and any other part of the fees that are not covered by my dental insurance company. I authorize release of any information necessary to process my dental insurance claim. I also authorize Dr. Iván E. Rodríguez, Dr. Adalí Efraín Vélez, and/or Dr. Ernesto G. Treviño to perform the diagnostic procedures and root canal treatment outlined above

Patient's Signature

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Parent/ Guardian Signature

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Doctor Signature

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Witness Signature

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