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HOME
ABOUT US
PROCEDURES
Same Day Dental Appointments
Emergency Dental Care
Cleanings & Prevention
Dental Exams & Cleanings
Dental X-Rays
Digital X-Rays
Fluoride Treatment
Home Care
How to Properly Brush & Floss
Oral Hygiene Aids
Sealants
Dental Restorations
Composite Fillings
Root Canal Therapy
Crowns (Caps)
Fixed Bridges
Inlay Restorations
Onlay Restorations
Dentures & Partial Dentures
Cosmetic Dentistry
Porcelain Crowns (Caps)
Porcelain Fixed Bridges
Porcelain Inlays
Porcelain Onlays
Porcelain Veneers
Tooth Whitening
Periodontal Disease
What is Periodontal (Gum) Disease?
Diagnosis
Treatment
Maintenance
Nitrous Oxide Sedation
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5 Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
FAQs
BLOG
News
SERVICE AREAS
Guelph
Exhibition Park
Downtown Guelph
Riverside Park
Clairfields
Grange Hill East
Kortright Hills
Old University
St. George’s Park
Village by the Arboretum
Book An Appointment
Endodontic (Root Canal) Therapy Informed Consent
Guelph Royal Dental
18 Douglas St,
Guelph, ON N1H 2S9
Phone: (519) 837-1870
Prior to undergoing Root Canal Therapy it is important that you read, understand and consent to the following:
The alternative to Root Canal Therapy is usually Extraction
The completed treatment usually takes between 1-3 visits
There is a 5-10% chance that the root canal therapy may not work. Further dental treatment may be necessary in such cases.
The treatment is generally painless but some discomfort may occur between visits which can be controlled pharmaceutically
Existing restorations, crowns, veneers or tooth structure may break as a result of root canal therapy
Instruments used to clean the tooth may break and/or perforate the internal part of the tooth
Complications may be encountered due to difficult tooth anatomy, blocked canals, preexisting treatment, split tooth, breakage of instruments inside tooth or perforations of the tooth.
Such complications may result in the necessity to extract the tooth, perform further dental treatment such as apical surgery and/or referral to endodontic specialist to complete the necessary treatment
Crown with or without post/core is strongly recommended to reduce the chance of fracture of the root canal treated tooth
The treatment has been discussed with my dentist and any additional questions and concerns have been addressed
Consent
*
I HAVE READ AND UNDESTAND THE ABOVE INFORMATION AND WISH TO PROCEED WITH THE ROOT CANAL THERAPY ON TOOTH
Patient’s Name
*
.
Tooth No (s)
*
Please enter a number(s) from 1 to 48.
Date
*
.
DD slash MM slash YYYY
Patient’s Signature
*
(Write Your Name)
Dentist/Treatment Coordinator
*
(Write Your Name)
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