Skip to main content
Walk In Family Dentistry
Phone:
(647) 799-6622
2365 Finch Ave W #201, North York, ON M9M 2W8, Canada
Walk-ins Welcome
Home
Patient Info
New Patients Form
Patient Forms
Cosmetic Dentistry Forms
Consent for Composite or Porcelain Veneers Form
Consent for Dental Crown Form
Bridge Prosthetics Consent Form
Crown And Bridge Form
Crown and Bridge Form Consent Form
voluntary and Informed Consent for Final Cementation
Surgical Forms
Consent For Full Dentures And Partial Dentures Form
Consent for Maxillary Sinus Elevation Surgery
Bone Grafting Surgery Consent Form
Crown Lengthening Surgery Consent Form
Gingival Grafting Surgery Consent Form
Dental Implant Consent Form
Extraction Consent Form
New patient forms
Patient Screening Form
Information Update Form
Patient Acknowledgement Form
Financial Agreement Form
Scaling & Root Planing Consent Form
Occlusal Guard Consent Form
Root Canal Therapy Information & Consent Form
Canadian Dental Care Plan
Non-insured health benefits
Dental Blog
Promotions
FAQs
Services
Routine Dental Care
Checkups, cleaning & prevention
Fix a Damaged Tooth
Fillings, crowns & root canal care
Replace Missing Teeth
Implants, dentures & replacement options
Improve My Smile
Whitening, veneers, bonding & alignment
General Dentistry
Root Canal North York
Tooth Extraction North York
Wisdom Tooth Extraction North York
Dental Cleaning North York
Restorative Dentistry
Dental Filling in North York
Dentures North York
Dental Crowns North York
Dental bridges North York
Cosmetic Dentistry
Dental Implants North York
Teeth Whitening North York
Dental Veneers North York
Dental Bonding North York
Smile Makeovers North York
Orthodontics
Retainers in North York
Invisalign North York
Emergency Near You
Emergency Walk-in Dentist
North York
Emergency Walk-in Dentist
Etobicoke
Emergency Walk-in Dentist
Downsview
Emergency Walk-in Dentist
Rexdale
Emergency Walk-in Dentist
Jane and Finch
Emergency Walk-in Dentist
Yorkdale
Emergency Walk-in Dentist
Humbermede
Who We Help
Student Dental Clinic
Dental Clinic for York University
Dental Clinic for Seneca Polytechnic
Dental Clinic for Centennial College
Dental Clinic for Humber College
Dental Clinic for Niagara University
Seniors
Low-Income Patients
Iranian Community
About
Our Practice
Our Dentists
Dr Vida Siar
Dr. Ardeshir Ranjbari
Dr Mahvareh Akhgar-Araghi
Dental Technology
Smile Gallery
Contact
Contact Page
Call
(647) 799-6622
Get Directions
2365 Finch Ave W #201, North York, ON M9M 2W8, Canada
Hours
Monday: 10 AM to 2 PM
Tuesday to Friday: 9 AM to 6 PM
Saturday: 9 AM to 3 PM
Sunday: Closed
Book Now
Emergency
Now Welcoming New Patients with Canadian Dental Care Plan (CDCP) Benefits.
"
*
" indicates required fields
Patient Information
Name
*
Date
*
MM slash DD slash YYYY
Information & Consent for Root Canal Therapy
Name:
*
Date
*
MM slash DD slash YYYY
Tooth #
*
Consent
*
I agree to the Consent.
1. Root Canal therapy is about 95 percent successful . Many factors influence the treatment outcome , the patient's general health bone support around the tooth , strength of the tooth Including possible fracture , line , shape and condition of the root and the nerve canal (s) , fill separation , etc.
2. The treated tooth many normally be sensitive following appointments and remain tender for a time after treatment is completed . If sensitivity persists , and does not seem to be getting , even several weeks after the root therapy is finished , call office immediately.
3. Teeth treated for root canal therapy must be protected during treatment . Between appointments your tooth will have a temporary filing . If this should come out , please call office Immediately and arrange to have It replaced.
4. Fractures are one of the main reasons why root canal treatment falls .DO NOT EAT ON THE TREATED TOOTH UNTIL PERMANENT CROWN IS PLACED . Unfortunately , some cracks that extend from the crown down into the root are Invisible and are virtually Impossible to detect . They can occur on uncrowned teeth from traumatic Injury , biting on hard objects , habitual clenching or grinding or even normal wear . Weather the fracture occurs before or after the root canal treatment the many have to be extracted.
5. You could experience possible lip numbness when treating lower premolar and molars.
6. Since tooth with Root Canal Treatment is more brittle than other teeth . It is highly recommended that a post / core and permanent crown be made to finally restore the tooth . Because the tooth is not hollow , or will fracture easily . It the tooth is not crowned , it may break rendering It unrestorable and consequently require extraction.
THE POST / CORE & PERMANENT CROWN / RESTORATION ARE SEPARATE PROCEDURES AND ARE NOT INCLUDED IN THE ROOT CANAL TREATMENT FEE ***
Patient Initials
*
Consent
*
I agree to the Consent.
7. With some teeth , conventional root canal treatment alone may not be sufficient . If the canal ( s ) are several bent or calcified , if there is substantial or long standing Infection in the bone , or if a metal file or Instrument becomes separated within a canal , the tooth may remain sensitive and surgical procedure may be necessary to resolve the problem.
8. When removing your existing crown the porcelain or tooth may chip or fracture . If the doctor must remove your existing crown to achieve proper access to the canals , the removal procedure may cause the crown porcelain or the tooth to fracture . Therefore , the crown may have to be remade or the tooth extracted.
9. There are alternatives to root canal therapy . They include no treatment at all , extraction with nothing to fill the space , and extraction followed by a bridge , partial denture , or implant to fill the space.
The nature and cost of root canal therapy and crown repair has been explained to me . I have all of me question answered related to root canal therapy and post / core crown repair . I understand that success with root canal treatment cannot be guaranteed and understand that root canal therapy is necessary .
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
*
Δ
