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Patient Information & Consent

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What is root canal treatment and what are its benefits?

Root canal treatment is the procedure of cleaning diseased or infected tissue from the inside of the tooth followed by placement of a hermetic seal in the resulting root canal space. Using a local anesthetic, there is little or no discomfort to the procedure. When swelling is present, root canal treatment may also involve incision of the gum, drainage of pus and the use of antibiotic therapy. The main benefit of treatment is saving a tooth which would otherwise require extraction, allowing it to contribute in a sound, healthy and functional dentition for many years, if not a lifetime. The practice of endodontics also includes procedures such as internal tooth bleaching, inducing closure of immature diseased roots, treatment of traumatic injuries, root end surgery and the fabrication of posts and buildups under crowns.

What are the complications of treatment?

With a success rate of approximately 90%, endodontic therapy is a very reliable dental procedure. Endodontic Specialists (Drs. Ross, Berkhoff, Thompson, Horspool, Schuurmans, Johnson, and Kennedy) are highly trained and use only approved materials with the latest techniques. However, because endodontic therapy is a biological procedure, there can be no absolute guarantee regarding treatment success. Some very infrequent complications and risks include the possibility of a split or fractured tooth, a damaged crown or bridge, separation of an instrument portion within the tooth which cannot be removed, and varying pain, swelling or infection. While rare, numbness of the lip, tongue, chin, cheek, or teeth can occur and may be irreversible. The use of prescription medications during the course of treatment may also result in unexpected drug reactions. Any of these complications could result in failure of the procedure requiring possible retreatment, surgery, and/or extraction. While we want to advise you of possible issues, many teeth are saved every day with no complications or side effects at all.

What alternatives do I have?

Extraction of the tooth is the alternative. If the tooth is removed and not replaced, the empty space can create problems in tooth alignment because of shifting. This often results in periodontal (gum) disease and eventual loss of additional teeth. The missing tooth on the other hand, may be replaced by a bridge, implant, or partial denture. The cost is more expensive than root canal treatment and may involve otherwise avoidable dental work on adjacent healthy teeth. Since bridges and partial dentures are also harder to keep clean, gum disease may result without meticulous home care. The option of no treatment results in the persistence or recurrence of pain, infection and eventual tooth loss. You are encouraged to seek a second opinion if you have any questions.

What are my responsibilities?

It is very important to provide your endodontist with a complete, accurate, medical history and health status on your health questionnaire, including any prior allergic or unusual reactions to drugs, food, anesthetics, or previous dental treatments. We also need to know about all your prescription and over the counter medications including aspirin and supplements.

Since only root canal treatment is performed at this office, it is your responsibility to make an appointment with your regular dentist for the permanent restoration (filling, crown, etc.).

Since the time of your appointment is reserved exclusively for you, it is important that you give us 24 hours notice if you must reschedule so that time may be given to someone else. It is also your responsibility to pay for dental services at the time they are rendered whether or not dental insurance coverage is in effect.

By my signature below, I acknowledge that I have read this consent form in its entirety and have been given the opportunity to ask questions. I hereby authorize Endodontic Specialists (Drs. Ross, Berkhoff, Thompson, Horspool, Schuurmans and Johnson, and Kennedy) to perform appropriate examinations, diagnostic procedures, and indicated treatment. I also acknowledge financial responsibility for these services and agree to pay for them in full by completion of treatment. I understand that if my account becomes delinquent, it may be forwarded to an outside collection agency. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees and collection agency costs.

I understand that the estimated down payment quoted for treatment today is only an estimate. I may receive a billing statement after my insurance responds to the submitted claim or I may receive a refund. _________ _______________
Initials Date
_______________________________________________
Print Patient Name
_______________________________________________ Date:___________________
Patient Signature
OR
Parent or Guardian Signature
(If patient is younger than age 18,
parental consent is required)

  • Colorado Springs North

    5745 Erindale Drive, Suite 200
    Colorado Springs, CO 80918
  • Colorado Springs South

    1230 Tenderfoot Hill Road, Suite 300
    Colorado Springs, CO 80906
  • Pueblo

    2099 U.S. Highway 50 West, 150A
    Pueblo, CO 81008