Information & Consent for Root Canal Therapy - Walk In Family Dental

"*" indicates required fields

Patient Information

Name*

Date*

Information & Consent for Root Canal Therapy

Name:*

Date*

Tooth #*

Patient Initials*

I authorized Dr.

Doctor Name*

to proceed with root canal treatment.

Date*
MM slash DD slash YYYY

SIGNATURE OF PATIENT (or Legal Guardian)*

SIGNATURE OF DENTIST*

SIGNATURE OF DENTAL ASSISTANT*