RTC Consent | Patient Form
RTC Consent
INFORMED CONSENT FOR ENDODONTIC TREATMENT
Patient Name
First Name
Last Name
Tooth/Teeth #
Retreat
This field is required.
Local Anesthesia:
By receiving local anesthetic, there is a possibility of temporary or permanent numbness of the lip, tongue, chin, cheek, as well as, thrombophlebitis (inflammation of the vein), temporary TMJ problems, and possible allergic reaction.
This field is required.
Nitrous Oxide (N20):
Nitrous oxide sedation is used for anxiety and pain control, as well as control of gagging. I understand that the patient will be awake and aware of surroundings and able to respond rationally to questions and directions. I understand I can drive myself to and from my appointment.
This field is required.
Patient Name
First Name
Last Name
Patient/Guardian Signature
Clear
Signature is mandatory.
Date
Doctor:
Type a sub label
Witness
Submit