Informed Consent for Endodontic Treatment / Retreatment

Please read carefully before signing.

It is important for us, the healthcare professional, to obtain your consent regarding the root canal (endodontic) treatment/retreatment that you will undergo, so that you can make a decision on whether to undergo this procedure after knowing the risks and complications. Please read this medical procedure agreement carefully and ask your dentist anything you don't understand.

Diagnosis: Root Canal Treatment (Please select one)

In general, endodontic treatment/retreatment procedures include:

  1. Local anesthesia, if necessary.
  2. Pre-treatment protection (artificial walls, ring, or temporary crowns) to keep the tooth safe and isolated, as needed.
  3. Cavity opening to get an access to root canal.
  4. Removing the nerve/s tissue (pulp) or old canal/s obturation material (gutta percha).
  5. Cleaning, shaping and sterilisation of root canal/s.
  6. Filling/obturation of root canal/s.

Consequences and Complications

Special Conditions

Hypertension (mmHg):
Heart disease:
Allergy to anesthesia:

I hereby certify that I have explained all relevant information accurately, clearly, and comprehensively to the patient. And that the patient has been given sufficient opportunity to ask questions, seek clarification, and participate in discussion regarding the proposed medical care.

Doctor's signature

I hereby state that I have received the information as described above, marked with a √ and have understood it.

Patient's signature

Note: in the event the patient lacks decision-making capacity or chooses not to receive the information, the information shall be disclosed to the patient’s legally authorized representative, guardian, or next of kin.