The forms contained in this chapter are only examples. Do not use them without the advice of your local legal counsel to ensure compliance with your state’s requirements.

GENERAL RELEASE FOR DENTAL TREATMENT
(MAY BE ADAPTED FOR PATIENT BY ELIMINATING THE FIRST SENTENCE)

I, ________________, am the _________________ (parent or guardian) of [name of patient]. I hereby authorize the doctor to perform any and all forms of dental treatment, medication, and therapy (with my prior consent) that may be indicated in connection with [name of patient] and further authorize and consent that the doctor choose and employ such assistance as he or she deems fit. I also understand that dental treatment and the use of anesthetic agents embodies a certain risk. If I have any questions or concerns, I will ask.

Signature_____________________ Date_____________

Relationship___________________

Witness_______________________ Date_____________

CONSENT FOR PULPAL DEBRIDEMENT AND ENDODONTIC TREATMENT
(ROOT CANAL TOOTH #______)

The purpose of endodontic (root canal) treatment is an attempt to save a tooth rather than to remove it. Although treatment has a high degree of success, it cannot be guaranteed. Pulpal debridement is the removal of the nerve within the tooth and the placement of medication to relieve pain. Sometimes the tooth may need to be reaccessed and remedicated. Occasionally, the tooth that had root canal treatment may require retreatment, surgery, or even extraction. Endodontic treatment is usually a nonsurgical procedure, but there are inherent risks and limitations such as, but not limited to, file separation (breakage), perforation of the root, calcification of canals, underfilling and overfilling of the canals, and the loss of the tooth. In addition, the porcelain on crowns (caps) can break on making entry to the root canals. This may necessitate replacement of the crown.

In some cases a surgical approach is necessary. There may be other complications such as, but not limited to, pain, bleeding, swelling, or infection. In addition, other complications such as sinus involvement, gum recession, numbness or tingling of the lips, face, tongue, or gums are possible. Before any treatment is undertaken, the reason for surgical treatment will be fully explained, including alternative modes of treatment.

Consent is hereby given for the use of local anesthetics, sedation, analgesia, and the use of any materials necessary to fill the root canal as deemed appropriate by the judgment of the dentist. Consent is also given to perform any necessary endodontic procedure that has been fully explained to me. The endodontic (root canal) procedure has been explained to me and I am satisfied that I understand what is to be done. Alternative treatments, including nontreatment, have been explained to me. Costs for the root canal have been explained. I have been given an opportunity to ask questions, and any questions have been answered to my satisfaction. After treatment, the tooth should be restored as soon as possible, usually with a crown (cap). A separate fee will be charged for the restoration.

Signature___________________ Date_________________

Witness____________________ Date_________________

CONSENT FOR ORAL SURGERY
(EXTRACTION OF TOOTH # _________)

The oral surgery procedure (extraction) to be performed has been explained to me as well as the alternatives and the ramifications of not having the tooth extracted. I consent to the oral surgery indicated and to other surgery deemed necessary or advisable by the judgment of the dentist, at the time of surgery, in addition to the planned surgery. I also consent to the use of local anesthetics, sedation, and analgesia as deemed necessary by the judgment of the dentist during the planned procedure.

I understand that occasionally there are complications associated with surgery. The more common complications are, but are not limited to, pain, infection, swelling, bleeding, bruising, and discoloration; temporary or permanent numbness, pain, burning, or tingling of the lip, check, tongue, chin, gums, and/or teeth; bone fracture; sinus involve/>