I have been informed that the purpose of the treatment is preservation of the tooth and that without the
treatment, it may become necessary to extract the tooth. It was explained to me about the treatment and
its anticipated results. The alternative treatments were considered by me prior to choosing this treatment.
I was informed of the possible risks involved in the treatment including:
1 . Incomplete root canal filling due to calcified or curved root.
2 . The development of infection or non-healing of preexisting infection.
3 . A crack or fracture in the root, which has been diagnosed during or at the end of the treatment.
4 . Fracture of tooth crown during or at the end of treatment .
5 . Breakage of file or instrument inside the root canal.
6 . Perforation of the tooth during treatment.
7 . Damage to existing restorations, crowns and porcelain coatings .
8 . Passage of the rinsing fluids / sealing materials outside the root apex and the development of swelling
and/or bone and/or sinus inflammation and/or neural injury. During/at the end of treatment, pains and/or
swelling may develop. In such cases, pain relievers and/or antibiotics should be taken. Unexpected
conditions may develop, requiring different treatment or referral to a specialist including the need for root
canal retreatment, removal of the very tip of the root (apicoectomy) or tooth extraction. I was informed
that a tooth during and after root canal treatment is a fragile tooth. In order to reduce the risk of a tooth
fracture, hard foods should be avoided and tooth restoration should be performed as soon as possible.
I confirm that I was informed of the importance of providing full and accurate information concerning my
health condition, sensitivity to drugs and reactions to anesthesia, as this information may impact the
treatment plan and the way of rendering the treatment in order to protect my health. My consent is also
given for local anesthesia, after I received explanations concerning the risks and complications of
anesthesia including loss of sensation in the lip and/or tongue and/or chin and/or face, hematoma,
swelling and limitation in mouth opening. Should it be decided to perform the Principal Treatment under
general anesthesia or intravenous sedation, the information about the anesthesia will be provided to me
by an anesthesiologist. I hereby give my consent to the performance of root canal treatment and I
understand the nature of the treatment, chances of success and possible risks and complications.
