Consent for root canal treatment
Consent for root canal treatment
Please fill out completely and sign.
Name
Name
First
Last
I hereby authorize (Doctor's Name)
and any associates to perform a root canal on tooth/teeth number(s):
7. Other Risks:
Patient or guardian signature(Draw your signature into the box below)
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
/
MM
/
DD
YYYY
Dentist Signature
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
/
MM
/
DD
YYYY