Permit for Endodontic Treatment
This is my consent for the doctors of HOBEICH ENDODONTICS to perform any necessary dental procedure(s) as
indicated by my dental examination. I understand that although root canal has a high degree of success, it is still a biological
procedure, and therefore success cannot be guaranteed. I have been informed and understand that there are certain inherent and
potential risks in a treatment procedure. These risks may include, but are not limited to, swelling, infection, bruising, discomfort,
and fractures of teeth and existing restorations. I understand that variations in tooth anatomy and canal shape may complicate
treatment and could result in a perforation (hole) in the root or separation of a metal root canal instruments in the tooth.
Additional treatment, surgical repair, or extraction may be necessary to resolve these problems.
Additional risks from local anesthesia (numbing) may include temporary alterations of heart rate, allergic reactions, and
temporary, or rarely, permanent nerve damage that may result in pain or numbness of the jaw, lip, or gums. Occasionally, there
may be muscle spasms that can restrict opening of the jaw for extended periods of time following root canal therapy and/or local
anesthesia. I understand that medications that may be prescribed either before or after treatment can have side effects that may
include, but are not limited to, drowsiness, nausea, allergic reactions, and intestinal problems.
I have been informed of possible alternative treatments including extraction and non-treatment and the possible benefits
or adverse results from these alternative treatments. I understand that a permanent restoration (filling or crown) is to be done by
my restorative dentist. I also understand that failure to have the permanent restoration completed may lead to failure of the root
canal therapy as well as possible fracture and/or infection of the treated tooth. This may result in the necessity for additional
treatment or extraction of the previously treated tooth.
I understand that root canal therapy is to be rendered if determined diagnostically.
PATIENT (GUARDIAN)
DATE
WITNESS
--------------------------------------------------------------------------------------------------------------------------------------------------Please read the following information if you are requesting either nitrous oxide or oral sedation. Those patients requesting
intravenous sedation will receive a separate consent form from the anesthesiologist.
Nitrous Oxide:
I accept and understand that the purpose of nitrous oxide sedation is to allow me to receive the necessary dental care
more comfortably and with less anxiety. I also understand and accept that the use of nitrous oxide has limitations and risks and
that absolute success cannot be guaranteed. I understand that sedation is not required to provide the necessary dental treatment,
and that alternatives to nitrous oxide sedation are, no sedation, oral sedation, and intravenous sedation. The most common effects
of nitrous oxide sedation include relaxation with a sense of heaviness or a light "floating" sensation. Occasional adverse side
effects may include, but are not limited to, nausea, vomiting, agitation, and/or hallucination.
I accept and understand that I must notify the doctor if I: ( 1) am pregnant, (2) have sensitivity to any medications, (3)
have recently consumed alcohol, and/or (4) am presently taking mood altering drugs or psychiatric medications.
PATIENT (GUARDIAN)
WITNESS
Date
Oral Sedation:
I accept and understand that the purpose of oral sedation is to allow me to receive the necessary dental care more
comfortably and with less anxiety. I also understand and accept that the use of oral sedation has limitations and risks and that
absolute success cannot be guaranteed. I understand that sedation is not required to provide the necessary dental treatment, and
that alternatives to oral sedation include no sedation, nitrous oxide sedation, and intravenous sedation. Most oral sedatives will
produce a sleep-like state, relaxation, and amnesia that will block any recollection of the dental procedure. I understand that I will
require a driver to transport me to and from my dental appointment. Occasional adverse side effects may include, but are not
limited to, nausea vomiting, cramps, confusion, respiratory depression, visual disturbance, muscular fatigue and/ or loss of
coordination, and hallucination.
I have received and reviewed printed instructions relating to my pre and postoperative care when receiving oral
sedation and I have had an opportunity to ask questions, and am fully satisfied with the answers I received.
I accept and understand that I must notify the doctor if 1: (1) am pregnant, (2) have sensitivity to any medications,
(3) have recently consumed alcohol, and/or (4) am presently taking mood altering drugs or psychiatric medications.
PATIENT (GUARDIAN)
Date
WITNESS