Patient Forms

I hereby authorize Dr. Johnson with the assistance of his employees to treat the condition that may be decided upon to be necessary or advisable in the opinion of the doctor. I understand that root canal treatment includes possible inherent risks such as, but not limited to the following, including the understanding that no promises or guarantees of results have been made no expected:

1. The teeth treated may remain tender or even quite painful for a period of time, both during and after completion of treatment.
2. There is a possibility of numbness occurring and/or persisting in the tongue, lips, teeth, jaws, and/or facial tissues which may be a result of the anesthetic administration or from treatment procedures. This numbness is usually temporary, but, rarely, could be permanent.
3. A crown (cap) may be damaged or destroyed during rubber dam application access preparation, or other procedures as part of endodontic therapy.
4. There exists the possibility of instrument separation (breakage) inside the tooth which may or may not be detected at the time of treatment.
5. I understand that only the root canal treatment, or treatment associated with this specialty is to be performed at this office. The permanent outside restoration (filling, inlay, crown etc.) will be done by my regular dentist.
6. Once treatment us begun, it is absolutely necessary that the root canal treatment must be completed. I understand I have the option to choose no treatment at all, and being aware that a tooth with a compromised pulp (nerve) has the potential to affect my health. I also understand I have the option to choose to have the tooth or teeth in question removed. Also being aware that it is then recommended to have the area replaced with an artificial prostheses.
7. I further acknowledge that many factors influence success of root canal treatment, and that although treatment is successful in the vast majority of teeth treated, and possibility of failure does exist, which may result in additional treatment, and in some instances the removal of the tooth.
8. I have read and understand all sections of the form and have been given the opportunity to ask questions and have received answers to my satisfaction. I also understand the fees for this service and agree to all things herein.

I hereby authorize Dr. Johnson with the assistance of his employees to treat the condition that may be decided upon to be necessary or advisable in the opinion of the doctor. I understand that root canal treatment includes possible inherent risks such as, but not limited to the following, including the understanding that no promises or guarantees of results have been made no expected:

1. The teeth treated may remain tender or even quite painful for a period of time, both during and after completion of treatment.
2. There is a possibility of numbness occurring and/or persisting in the tongue, lips, teeth, jaws, and/or facial tissues which may be a result of the anesthetic administration or from treatment procedures. This numbness is usually temporary, but, rarely, could be permanent.
3. A crown (cap) may be damaged or destroyed during rubber dam application access preparation, or other procedures as part of endodontic therapy.
4. There exists the possibility of instrument separation (breakage) inside the tooth which may or may not be detected at the time of treatment.
5. I understand that only the root canal treatment, or treatment associated with this specialty is to be performed at this office. The permanent outside restoration (filling, inlay, crown etc.) will be done by my regular dentist.
6. Once treatment us begun, it is absolutely necessary that the root canal treatment must be completed. I understand I have the option to choose no treatment at all, and being aware that a tooth with a compromised pulp (nerve) has the potential to affect my health. I also understand I have the option to choose to have the tooth or teeth in question removed. Also being aware that it is then recommended to have the area replaced with an artificial prostheses.
7. I further acknowledge that many factors influence success of root canal treatment, and that although treatment is successful in the vast majority of teeth treated, and possibility of failure does exist, which may result in additional treatment, and in some instances the removal of the tooth.
8. I have read and understand all sections of the form and have been given the opportunity to ask questions and have received answers to my satisfaction. I also understand the fees for this service and agree to all things herein.