false
17
Endodontic Consent Long
Consent
11
Microsoft Sans Serif
850
1100
false
1
false
false
25677
17
StaticText
Consent for Treatment
11
Microsoft Sans Serif
true
50
800
180
19
None
false
0
Left
false
-16777216
false
25678
17
StaticText
I have read the above and I understand that no treatment is without some measure of risk; and the risks of the proposed treatment have been explained to me. I prefer to undergo the ENDODONTIC (root canal) procedure in order to attempt to postpone the loss of my tooth. I hereby authorize the doctors and their assistants to perform the necessary endodontic procedures which have been described to me. I further request and authorize them to do whatever they deem advisable and necessary as a result of unforeseen circumstances. It has been explained to me and I understand that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted. I have been given the opportunity to question the doctor concerning the nature of treatment, the inherent risks of the treatment, and the alternatives to this treatment.
11
Microsoft Sans Serif
false
50
820
750
152
None
false
0
Left
false
-16777216
false
25676
17
StaticText
After completion of the root canal therapy, it is my responsibility to ensure final restoration of the involved tooth, which is to protect my tooth from decaying or fracturing. Failure to have a crown or a filling after completing my treatment may result in the failure of the root canal and/or loss of the tooth.
I am also aware that exposed to the oral cavity without any protection, a successful root canal treatment may fail in as short as 2 weeks.
11
Microsoft Sans Serif
true
50
686
750
112
None
false
0
Left
false
-16777216
false
25675
17
Rectangle
0
false
46
685
756
113
None
false
0
Left
false
-16777216
false
25674
17
StaticText
Endodontic treatment is a highly successful procedure for postponing the loss of teeth that would otherwise be extracted. Unfortunately, not all teeth will respond favorably to the treatment. Consequently, it is possible that in the future, my tooth may require additional treatment such as another endodontic procedure, surgery, or even extraction.
As for all dental procedures, I understand it is not possible to guarantee the success of the endodontic procedure, despite all of the efforts of the doctors.
Medications may be given for pain or infection. If given pain medication, I should not drive an automobile nor operate equipment that may be hazardous to me or others. If I am a female who is taking birth control pills, it is possible that I could become pregnant while taking an antibiotic. Consequently, an alternative form of contraception may be appropriate while taking the antibiotic.
11
Microsoft Sans Serif
false
50
476
750
208
None
false
0
Left
false
-16777216
false
25673
17
StaticText
Swelling; sensitivity; bleeding; pain; infection; numbness and/or tingling sensation in the lip, tongue, chin, gums, cheeks and teeth, which is transient but on infrequent occasions may be permanent; reactions to injections; jaw muscle cramps and spasms; temporomandibular joint difficulty; loosening of teeth, crowns or bridges; delayed healing; sinus perforations; treatment failure; complications resulting from the use of dental instruments (broken instruments - perforations of tooth, root, sinus), medications, anesthetics, and injections; extruded gutta-percha and/ or sealer; root perforations; ingestion of sodium hypochlorite or extrusion of sodium hypochlorite; fracture of porcelain crowns; discoloration of teeth; reactions to medications; and antibiotics may inhibit the effectiveness of birth control pills.
11
Microsoft Sans Serif
false
70
323
730
152
None
false
0
Left
false
-16777216
false
25672
17
StaticText
Risks or complications are rare, but some may still occur. The doctor has explained to me that there are certain inherent and potential risks in any treatment plan or procedure. I understand that the following may be inherent or potential risks for the treatment I will receive:
11
Microsoft Sans Serif
false
50
265
750
57
DownLocal
false
0
Left
false
-16777216
false
25671
17
StaticText
What are the possible complications?
11
Microsoft Sans Serif
true
50
246
295
19
None
false
0
Left
false
-16777216
false
25669
17
StaticText
What are my Alternatives?
11
Microsoft Sans Serif
true
50
151
215
19
None
false
0
Left
false
-16777216
false
25670
17
StaticText
Alternatives to root canal treatment are to have no treatment done, wait for more definitive symptoms or to have the tooth extracted. If no treatment is done, there is the risk of infection, spread of infection to other areas, pain and/or loss of the tooth. If the tooth is extracted, then some form of an artificial replacement tooth may be constructed.
11
Microsoft Sans Serif
false
50
170
750
76
None
false
0
Left
false
-16777216
false
25668
17
StaticText
Tooth number(s):
11
Microsoft Sans Serif
false
50
113
120
19
None
false
0
Left
false
-16777216
false
25667
17
StaticText
Root Canal Treatment Consent
12
Microsoft Sans Serif
true
200
40
250
20
None
false
0
Left
false
-16777216
false
25666
17
OutputText
patient.nameFL
11
Microsoft Sans Serif
false
50
95
220
19
None
false
0
Left
false
-16777216
false
25665
17
OutputText
dateTime.Today
11
Microsoft Sans Serif
false
50
75
120
19
None
false
0
Left
false
-16777216
false
25679
17
SigBox
0
false
50
972
364
81
None
false
0
Left
false
-16777216
false
25680
17
StaticText
Signature
11
Microsoft Sans Serif
false
50
1053
90
19
None
false
0
Left
false
-16777216
false
25681
17
InputField
toothNum
11
Microsoft Sans Serif
false
170
113
100
19
None
false
0
Left
false
-16777216