Apicoectomy Consent Form

A consent form for surgical endodontic treatment. Fields cover the patient name, date of birth, tooth or area, and procedure date. Section one explains that an apicoectomy removes the tip of the root and infected tissue and seals the root end, usually after a root canal has not resolved the problem. Section two lists risks, including pain, swelling, bruising, bleeding, infection, damage to nearby teeth or restorations, sinus involvement for upper teeth, and numbness.

Review it with the patient at the consultation and get the signature before surgery. The doctor or surgical assistant answers questions, and the form is saved to the chart.