Root Canal Treatment Information and Consent Form

I, the undersigned hereby agree that on me / on my child / on the person under my guardianship / on my foster child (hereinafter: the Patient) a root canal treatment (. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .) be performed (the tooth concerned is: . . . . . . . . . . . . . . . . . . . . . . . . . . ) after the dentist - in the framework of the obligatory “provision of information” had told me about the outcome to be expected, the duration, the price and the possible risks – which may occur in spite of all precautions taken and which may involve among others the following.:

• complaints regarding the tooth concerned during and after the treatment,
• formation of a swelling,
• perforation of the root canal or the pulp chamber,
• breaking of the instruments used during the root canal treatment when in the root canal
• the root canal filling reaching beyond the root canal (maxillary sinus, canalis mandibularis),
• incomplete root canal filling that makes the repetition of a root canal filling necessary,
• development of an allergic reaction to the filling materials
and about the possible risks when a treatment is omitted:
• permanent pain, the spreading of the infection towards the jaw-bone, formation of an abscess

and I was informed of the consequences of the additional treatments.

During the root canal treatment generally 3-4 X-rays are taken (according to the regulations) but occasionally more are needed and these have to be paid for.
I was adequately informed about what to expect regarding the life-span of the root canal treated tooth, the success of the therapy and the possible complications. I was expressly informed that the root canal treatment aims at the retention of the tooth and no guarantee can be assumed. I was also informed that for four years after the treatment once in every six months (in some cases once in every year) check-up X-rays must be taken in order to find and to treat eventual complications. Signing up for these check-ups is the responsibility of the Patient. The success of the root canal treatment can only be judged 4-5 years after the treatment.
With the passing of the 4th year check-up X-rays of the treated tooth must be taken only once in every 5 years.

The cost of the changing / modifying / removing the prosthesis on the root canal treated tooth must be born by the Patient in the following cases:

• when the prosthesis for the root canal treated tooth is prepared when the success of the treatment cannot yet be adequately judged
• when the root canal treated tooth is fractured after the treatment.

I was also informed of the root canal treatment’s alternative therapy (the removal of the tooth).

I do not have any other questions.

Esztergom, 20.........................