PULPOTOMY INFORMED CONSENT
______________________________________ _________________________
Patient’s Name Date of Birth
This form and your discussion with your child’s doctor are intended to help you make an informed
decision about your child’s procedure. As a member of the treatment team, you have been informed of
your child’s diagnosis, the planned procedure, the risks, benefits, and alternatives associated with the
procedure, and any associated costs. In order to increase the chance of achieving optimal results, you
have provided your child’s complete medical history, including all past and present dental and medical
conditions, prescription and non-prescription medications, any allergies, recreational drug use, and
pregnancy (if applicable). Your doctor will be happy to answer any questions you or your child may have,
and provide additional information before you decide whether to sign this document and proceed with
the procedure.
Diagnosis: ___________________________________________________________________________
Procedure: ___________________________________________________________________________
Tooth Number(s):______________________________________________________________________
Alternative options: ____________________________________________________________________
1. I have been informed of and understand the potential risks related to this procedure include but are
not limited to:
Varying lengths and degrees of sensitivity, bleeding, infection, gum irritation, numbness that
may be permanent, risk of tooth fracture, damage to adjacent teeth, cracking and/or
stretching of the corners of the mouth, stress to the jaw joints (TMJ), altered bite,
instrument separation, possible breakage/dislodgement/bond failure of material, change in
aesthetic appearance of teeth, allergic and/or adverse reaction to medications and/or
materials.
This procedure will not prevent future tooth decay, tooth fracture or gum disease, and
occasionally a tooth that has had a pulpotomy may require re-treatment, Root Canal
Therapy or tooth extraction.
2. We have elected to proceed with the anesthesia(s) indicated below.
______ Local Anesthesia
______ Nitrous Oxide (Laughing Gas)
______ For mild (anxiolysis/“reduction of anxiety”), moderate (conscious/twilight), or deep
sedation/general anesthesia, sign attached Advanced Anesthesia Informed Consent
I have been informed of and understand the potential risks associated with anesthesia include but
are not limited to:
Allergic or adverse reactions to medications or materials, pain at the anesthesia injection site,
bruising/swelling, nerve injury, nausea, vomiting, disorientation, confusion, lack of
Patient’s Initials __________
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PULPOTOMY INFORMED CONSENT
______________________________________ _________________________
Patient’s Name Date of Birth
coordination, drowsiness, heart and breathing complications, numbness following anesthesia
that in rare instances may be permanent, overdose.
3. I further understand that the use of protective stabilization may be become necessary in the interest
of safety for the patient, staff, or guardian. Protective stabilization may include: mouth prop, the use
of a stabilization board, fabric wraps, Velcro® materials, or being restrained by a parent, guardian,
and/or dental staff member. Possible risks and complications that have been explained to me
include: distress and/or chance of injury including bruising or skin abrasion.
4. I have been informed of and understand that follow up visits or care, additional evaluation and/or
treatment may be needed.
5. Patient’s Responsibilities
I agree to have my child follow all instructions provided to us by this office before and after the
procedure, take medication(s) as prescribed, practice proper oral hygiene, keep all appointments,
make return appointments if complications arise, and complete care. I will inform my child’s doctor
of any post-operative problems as they arise. Our failure to comply could result in complications or
less than optimal results.
I understand and accept that the doctor cannot guarantee the results of the procedure. I had
sufficient time to read this document, understand the above statements, and have had a chance to
have all my questions answered. By signing this document, I acknowledge and accept the possible
risks and complications of the procedure and agree to proceed.
___________________________________ ____________
Parent or Legal Guardian Signature Date
__________________________________________________________________________
Print Parent or Legal Guardian Name/Relationship
_______________________________ ____________
Witness Signature (optional) Date
I certify that I have explained to the patient and/or the patient’s legal guardian the nature, purpose,
benefits, known risks, complications, and alternatives to the proposed procedure. The patient
and/or patient’s legal guardian has voiced an understanding of the information given. I have
answered all questions to the best of my knowledge, and I believe that the patient and/or legal
guardian fully understands what I have explained.
____________________________ ____________
Doctor Signature Date
Patient’s Initials __________
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