Donald L. Taylor, Jr., D.D.S.
534-A Wythe Creek Road
Poquoson, Virginia 23662
(757) 868-9334
ENDODONTIC CONSENT FORM
I understand that root canal treatment is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is a biological procedure, and results cannot be guaranteed.
I also understand that occasionally a tooth which has had root canal therapy may require re-treatment. In addition, approximately 10% of teeth that had root canal treatment may require an additional procedure, such as surgery at the root tip, at a later time. Even after root canal therapy, re-treatment and/or surgery, a small percentage of teeth (5%)
will nevertheless require extraction.
I also understand that only the root canal treatment is to be performed at this time. The final restoration (filling, onlay, crown, etc.) needs to be done as soon as possible to prevent the tooth from splitting.
Signed: PATIENT or PARENT:________________________________
Date:________________________________