Informed Consent Form

Root Canal Treatment (Endodontic Therapy)

1. PATIENT DETAILS

Patient Name

Age

Gender

Male Female

Contact Number

Email (optional)

Address

Medical History Reviewed

Yes No

If yes, attach / mention details

Allergies (if any)

Current Medications

2. PROCEDURE

Treatment / Procedure

Root Canal Treatment (Endodontic Therapy)

Tooth / Teeth Involved

Brief Explanation

The infected or inflamed pulp (nerve) inside the tooth will be removed. The root canals will be cleaned, shaped, disinfected and sealed to save the natural tooth.

3. BENEFITS

Relieves pain and infection.
Saves your natural tooth.
Prevents the need for extraction.
Restores function and comfort.
Helps maintain normal appearance and chewing ability.

4. RISKS & COMPLICATIONS

Mild to severe pain or discomfort during or after treatment.
Swelling or tenderness.
Infection may persist or recur.
Root canal may not be completely sealed.
Fracture of the tooth or instruments during treatment.
Need for retreatment or surgery.
In rare cases, extraction may be required.

5. ALTERNATIVES

Alternative Treatment Options: Extraction, medication, or no treatment.

Option of No Treatment: The infection may worsen, causing pain, swelling, abscess, bone loss and eventual tooth loss.

Consequences of Delaying / Refusing Treatment: Increased pain, infection spread, damage to surrounding teeth and bone, potential tooth loss.

6. PATIENT ACKNOWLEDGEMENT

I have been informed about the nature of the procedure, its benefits, risks, possible complications, alternatives and the consequences of not having the treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

7. CONSENT

I voluntarily consent to undergo the above-mentioned procedure.

Patient / Guardian Signature

(sign after printing)

Dentist Signature

(sign after printing)

Witness Signature (if applicable)

(sign after printing)

FOR CLINIC USE — PATIENT COPY

اردو میں رضامندی کا بیان (Urdu Consent Statement)

ڈاکٹر نے مجھے میرے دانتوں کے علاج کے طریقہ کار، ممکنہ خطرات، فوائد اور متبادل علاج کے بارے میں مکمل طور پر بتایا ہے۔

تمام سوالات کے جوابات سے میں مطمئن ہوں اور اپنی مرضی سے اس علاج کے لیے رضامند ہوں۔

This document is a record of informed consent and does not replace professional legal advice. Retain a signed copy in the patient’s file.