____________________________________________________     I hereby authorize

Patient Name

Dr. Bryan Bauer to perform a root canal treatment on tooth number  _________________

The intent of this procedure is to eliminate pain and infection in order to save the tooth from extraction.  Alternatives of doing nothing or extracting and possibly replacing the tooth were made known to me.

RCT has an approximate 85-95% success rate.  The doctor has explained to me that there are certain potential adverse outcomes inherent to any root canal that include:

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Unforeseen conditions may exist or arise during the procedure that require a different approach to treat and necessitate referral to specialist or result in the root canal not being able to be performed successfully.  There will still be a charge for work done; classified as either a pulpotomy, pulpectomy or the entire root canal procedure based on the individual circumstances.  I understand that a root canal alters the tooth structurally and that back teeth will require a crown and a post/buildup.  These future procedures are not part of the root canal fee and I am aware of what the approximate cost of these future procedures will be.  The dentist has explained to me the importance of future coverage with a crown and I will be following through in the near future with the recommendations.

Root canal therapy can fail during or after completion of work and it may fail for unexplainable reasons; such as an unidentifiable slowly growing crack.  I am aware that the practice of dentistry, like all phases of medicine, is not an exact science; and I acknowledge that no guarantees have been made to me concerning the results of the treatment.  If an instrument separates, an attempt to retrieve the file will be made based on the risk analysis of doing so at that time.  I will be informed if this occurs and will be advised on how to go forward.   If during the first year the RCT fails for any reason and there is reason to believe it can be retreated successfully, Dr. Bauer will do so at no charge or put your money towards a specialist of his choice to retreat the tooth.  All of my questions have been answered by the dentist and I fully understand all the above statements contained on this form.

If I have severe pain or pain lasting longer than 2-3 days, experience any swelling, or have an unexpected reaction to any medication I will call the office immediately.

Patient, parent, or guardian

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Doctor                                                                                                  Date