I authorize and request Dr. Cercek or Dr. Pittel to perform the needed root canal treatment. I have been informed of the available alternatives to endodontic treatment, which may include: 1) extraction of the tooth, 2) no endodontic treatment, which may result in a continuation or worsening of the condition and symptoms.

I understand that root canal treatment is an attempt to save a tooth which may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally a tooth which has had root canal therapy may require retreatment, surgery or even extraction.

This authorization is given with the understanding that any procedure or operation involves some risks and hazards. The risks with endodontic treatment include: the possibility of instruments broken within the root canals; perforation (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns or porcelain veneers; loss of tooth structure in gaining access to canals; and cracked teeth. In addition, the following complications may occur: swelling, bleeding, pain; infection; permanent numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth; changes in occlusion (bite); temporomandibular (jaw) joint difficulty; muscle cramps and spasms; tenderness of teeth; referred pain to ear, neck and head; nausea; vomiting; allergic reaction; delayed healing and sinus complications.

Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs; thus I should not operate any vehicle or hazardous devices or work while taking medications and/or drugs for at least 24 hours, or until I am fully recovered from the effects of the medications or drugs.

It is the patient’s responsibility to seek attention should any complications occur post-treatment. If I have any questions or concerns, I should contact the office immediately. If additional procedures to found during treatment, I authorize Dr. Cercek or Dr. Pittel to perform such further treatment as is necessary. If complications should arise during or after treatment it is possible that additional procedures may need to be performed. This may involve referral to other practitioners for treatment. Should referral to other practitioners be necessary, I authorize Dr. Cercek or Dr. Pittel to release the information on my health history to the treating practitioners.

I, the undersigned, being the patient (Parent or guardian if the patient is a minor), have read and fully understand this consent form, and I understand I should not sign this consent form, including all of my questions have not been explained or answered to my satisfaction, or if I do not understand any of the terms or words contained in this consent form. I also understand that upon completion of root canal therapy I will need a permanent restoration on the tooth involved, and it is my responsibility to consult with my primary dentist to determine the appropriate restoration.