Form root canal consent

An informed consent form for root canal treatment. The patient authorizes the dentist to perform endodontic therapy on a specific tooth, including local anesthetic and radiographs, and acknowledges that the plan may change once treatment starts, possibly to a pulpotomy, apicoectomy, extraction, or no further treatment. Initialed statements cover the right to decline, the risks of declining, that success is not guaranteed, and that changes to the plan can affect cost.

Present it before the root canal begins, ideally when the patient accepts the treatment plan. The doctor or assistant explains each initialed item, and the signed copy is scanned into the chart.