STATEMENT OF CONSENT FOR ENDODONTIC TREATMENT

1.     I hereby authorize Dr. __________________________ and any other agents or employees of
        _________________________________ and such assistants as may be selected by any of them
        to treat the condition(s) described below: ____________________________________________
        ____________________________________________________________________________
        ____________________________________________________________________________

2.     The procedure(s) necessary to threat the condition(s) have been explained to me, and I
        understand the nature of the procedure(s) to be: ________________________________________
        ____________________________________________________________________________
        ____________________________________________________________________________


3.     The prognosis for this (these) procedure(s) was described as: __________________________
        _____________________________________________________________________________
        _____________________________________________________________________________


4.     I have been informed of possible alternative methods of treatment including no treatment at
       all.

5.     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:

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; changes in occlusion (biting);

jaw muscle cramps and spasm; temporomandibular joint difficult; loosening of teeth,
crowns or bridges; referred pain to ear, neck and head; delayed healing; sinus
perforations; treatment failure; complications resulting from the use of dental
instruments (broken instruments-perforation of tooth, root, sinus), medications,
anesthetics and injections; discoloration of the face; reactions to medications causing
drowsiness and lack of coordination; and antibiotics may inhibit the effectiveness of
birth control pills.

6.     There is a method of root canal treatment known as the Sargenti Technique.  This technique
        relies heavily on a formaldehyde-containing paste.  In addition to the risks outline in
        paragraph five above, this technique has the following inherent or potential risks:
        paresthesias, dysesthsia, abscesses, inflammation, necrosis, fusion of tooth to bone and root
        resorption.  This technique is not recommended by the American Association of
        Endodontists.

7.     It has been explained to me and I understand that perfect result is not guaranteed or
warranged and cannot be guaranteed or warranted.

8.  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.

9.     This consent form does not encompass the entire discussion I had with the doctor regarding
the proposed treatment.


Patient's Signature _________________________________         Date/Time__________
Doctor's Signature__________________________________        Date/Time__________
Witness' Signature__________________________________        Date/Time__________