Dentistry On Bleams 
Informed Consent for Endodontic Therapy
ACKNOWLEDGEMENT OF INFORMED CONSENT
- I hereby acknowledge that I have been presented with and understand the major treatment considerations, including benefits, and potential risks (including but not limited to the possibility of instrument fracture in the root canal) and their management, and outcome of endodontic therapy. I also understand that there may be other problems that occur less frequently or are less severe.
- Dr. Chhavi Saxena and Associates have discussed the endodontic therapy for tooth/teeth with me. Dr. Chhavi Saxena and Associates have also presented me with alternative treatment options, and she has discussed with me their benefits, potential risks, possible complications and their management, and the approximate fees. I have been asked to make a choice about the treatment.
- Dr. Chhavi Saxena and Associates have presented information to aid in the decision-making process, and I have been given the opportunity to ask her all the questions that I may have about the proposed treatment, the treatment considerations, and the procedures. She has given me an explanation of and understands, the risks and complications of no treatment, which include but are not limited to the loss of tooth/teeth, a facial infection, and a cyst formation.
- I have been informed and understand that in the event of endodontic therapy, the existing restoration may have to be damaged or removed and subsequently may require repair or replacement. In such an event, it will be my responsibility to pay for the replacement or restoration. I have also been informed that a crown will be needed after the root canal treatment has been completed on the same tooth.
- I know that the practice of dentistry is not an exact science and, therefore, reputable dentists cannot guarantee results. I assure you that no guarantee or assurance has been made by Dr. Chhavi Saxena and Associates regarding the outcome of the treatment. I also understand that there will be a fee for any additional procedures required in the future in case the treatment is not successful and that the fee paid for the initial treatment will not be refunded or deducted.
- I have been informed and understand that the scheduling of treatment sessions may have to be changed if so, judged by Dr. Chhavi Saxena & Associates.
- I have been advised that a crown is necessary on the tooth after root canal treatment has been completed otherwise there is a risk of the tooth breaking resulting in the tooth needing extraction.
CONSENT TO UNDERGO TREATMENT
- I hereby consent to the taking of diagnostic records (including radiographs) before, during and after treatment, and to Dr. Chhavi Saxena & Associates providing treatment of tooth/teeth.
I understand that I am responsible for the financial aspect of my above treatment.