This authorization and consent for treatment is given to Dr.  Miller and staff after first having had a full explanation of the proposed treatment. This disclosure is not meant to frighten me. It is simply an effort to make me better informed so I may give or withhold my consent. The doctor has explained that his/her diagnosis is _____________________________ and has advised me than in his/her opinion root canal treatment is indicated. The doctor has advised me in his/her opinion and the consequences of not treating this condition include but are not limited to: worsening of the disease, infection, cystic formation, swelling, pain, loss of tooth, and/or other systemic disease manifestations. The doctor has advised me of alternative treatments, benefits, and risks which include are not limited to: extraction of the infected tooth (teeth) or not treatment or referral to a specialist (endodontist). I, however, believe that the root canal as noted above would be my preferred choice of treatment. The doctor has advised me that there are certain risks and potential consequences of any treatment and such risks would include but are not limited to: • A certain percentage (approximately 5-10%) of root canals fail, necessitating re-treatment, root surgery (with a referral to a specialist), or extraction. • Postoperative discomfort, swelling, restricted jaw opening which may persist several days or longer. • Breakage of root canal instrument during treatment which may, in the judgement of the doctor, be left in the treated root canal or require surgery by a specialist for removal. • Perforation of the root canal with instruments which may require additional surgical corrective treatment by a specialist or result in loss of tooth. • Premature loss of tooth due to progressive periodontal (gum) disease. • Root canal treatment relies heavily on radiographic information. Since radiographs are essentially 2-dimensional shadows which provide reliable but not infallible information, this may lead to root canal failures. • Successful completion of the root canal procedure does not prevent future decay or fracture. The endodontically treated tooth will be more brittle and may discolor. • In most cases, a crown and post filling is recommended after completion of the root canal to prevent fracture and/or improve esthetics. The endodontic fee  does not cover the cost of a crown.

I have read and understand the above and had all my questions answered to my satisfaction. I agree to proceed with the recommended root canal therapy.

           ________________________________________ ____________________

                     Patient’s Signature                                          Date

A Preventive Dental Practice

 Richard A. Miller DDS,FAGD

The Healthy Mouth