The most natural way to replace a missing tooth.
I hereby give permission to DENTAL ELEMENTS to perform ROOT CANAL THERAPY and such additional procedures as are considered necessary on the basis of findings during the course of said treatment.
I have been informed of alternative treatment options, benefits and possible risks and after the dentist’s explanation, I have chosen said treatment.
I understand there are various inherent or potential risks that can occur as a result of said procedure(s) despite all efforts to the contrary which include but are not limited to:
I understand that the administration of anesthesia and/or medications carry certain inherent risks, such as, but not limited to:
I also understand root canal therapy is a filling of the internal canals of the tooth and that a final outside restoration (usually including a build-up and crown) will be necessary following root canal treatment. Since the blood supply is removed from the tooth, it has a tendency to become more brittle and may discolor.
I understand that a series of appointments may be necessary to complete the root canal therapy, as well as additional appointments for the final restoration.
I further understand that this procedure(s) can also be performed by a specialist and prefer that this treatment be rendered in this office by a general dentist.
The dental care and treatment to be performed has been explained to me and I understand what is to be done and that there is no warranty or guarantee as to any result and/or cure. I may ask the attending dentist for a more complete explanation.
This is my consent for said procedure(s), anesthetics and x-rays to be taken.
I hereby acknowledge I have completely read and understand the foregoing; have been given the opportunity to discuss this form and question the dentist concerning the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment, and have been given satisfactory answers and agree to proceed with recommended procedure(s). I am aware the practice of dentistry is not an exact science and acknowledge that no promises or guarantees of results have been made nor are expected.
This consent form does not encompass the entire discussion I had with the dentist regarding the proposed treatment.
I acknowledge full responsibility for the payment of these services and agree to pay for them in full at or before completion, unless other specific arrangements have been made.
I had a long overdue deep cleaning, root canal/crown, AND fillings within a month. Dr. Thurman, Morgan, Kathy and staff were very attentive and kind with not ONLY the procedures and explanations but with checking up on me after the root canal. Also great at helping me figure out my insurance coverage and payments. Dental Elements is GREAT.- Steve
Your Decision to Choose Us as your Dental Health Partner is a Great Compliment.