+62 812 3446 161 | +62 2258 2923

Jl. Puri Kembangan Timur F1 No. 39 RT. 1/RW. 5, Kembangan Selatan, Jakarta Barat 11610
gmail: putihdental@gmail.com | www.putihdental.com | ig : @putihdentalcenter

DENTAL CONSENT – ROOT CANAL TREATMENT

I, who fill this consent form:

Name :

Sex :

Birth Date :

Adress :

Contact Number :

As the parent / guardian of:

(fill the data below if you are not the patient who will receive the treatment)

Name :

Sex :

Birth Date :

Adress :

Contact Number :

Treatment scheme

I understand and was explained clearly by drg. ____________________ that at this day I will have
these treatment(s) performed:

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All treatments advised by the doctor(s) was conducted based on the anamneses, medical/dental
examination, radiology findings, and other diagnostic examinations that are required.

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Based on the treatment(s) above, the total estimated bill that will be charged are shown below:

1. Endo/Re-treatment Rp._______________________
2. Crown Endo Rp. 7.950.000,- per tooth
3. Fiberpost/EverX Rp. 850.000,- per tooth
4. Re-walling Rp. 750.000,- per tooth
5. Broken File Removal Rp. 1.000.000 – Rp. 2.000.000,- per tooth
6. Complicated case of treatment Rp. 500.000,- per passage
Endo/Re-treatment + Crown package = 10% Discount
Package above exclude*:
- Re-walling
- Fiberpost/EverX
- Broken File Removal
- Complicated case of treatment.
Additional treatment(s) mentioned above are conducted based on dental/clinical findings during
examination.
If a patient choose to take the Endo/Re-treatment + Crown package, all excluded treatment
mentioned above (*) will also subjected to 10% Discount.
Package discount is valid with full payment only (no installment).

Risk of the Treatments

I acknowledge and fully understand that all medical treatments, along with their benefits, have their
own risks. Therefore, I accept that risk and complication are fitting in all kind of medical practice.

All the doctors at PUTIH will always do their best to minimalized complications or risks that could be
occurring.

Below are risk(s) and complication(s) that could occur during my root canal treatment:

- Pain and discomfort after treatment

- Temporary or permanent sore of mouth area
- Swelling
- Left behind instrument(s) inside the tooth
- Perforated root canal
- Dead-end of root canal
- Flawed recovery of infection
- Infection after root canal treatment that requires additional care and medication
- Defection of root canal during treatment that result in need of extraction of the tooth
- Fracture, chipping, cracking, or loss of dental crown (in all cases of natural teeth or dentures)

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 - Change of bite and other jaw problems
- Allergic reaction after drugs and other dental material administration during treatment
- Good restoration of tooth is required after each treatment based on the recommendation of the
dentist to achieve a successful root canal treatment and to avoid complications such as tooth
fractures.
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I was given the time to ask about all the risks and complications regarding my treatment(s) and have
been contented with the explanation.

I also have been given the chance to discuss regarding my treatment options based on my dental
findings and needs.

Medical Information Validity

I hereby announce that all medical information I provided to PUTIH doctors including medical
history, past medication, past therapy and surgery history (with document attached if required) are
true and valid.

Agreement
- I hereby declare that I fully APPROVE to undergo treatments advised at PUTIH with full
understanding regarding the risks and complications I may run into.
- I understand that dental practice does not took on a 100 percent certitude and there is no
guarantee of its end result.
- I have received a complete guidance regarding the treatment(s) that will be conducted, all the
risks and complications, other treatment options, total bill amount, also enough time to have a
discussion related to the treatment(s) with contentment.
- I fully APPROVED and AUTHORIZED all treatment advised by PUTIH doctor(s) to be
conducted.

Jakarta,

drg. Patient:

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Witness: Family/Guardian:

Emergency contact:
Name:

Relation:

Phone Number:

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