Root Canal Treatment Agreement

This agreement is entered into between _____________________ and Teeth Hub Dental Clinic for the provision of Root Canal Treatment.

Treatment Details:

  1. Procedure: The Clinic agrees to perform root canal treatment on the following tooth/teeth: _______________
  2. Scope of Treatment: The treatment includes diagnosis, root canal therapy, and necessary follow-up appointments.
  3. Treatment Plan: The Clinic will adhere to the treatment plan agreed upon between the Patient and the attending dentist. Any modifications or changes will be communicated and approved by the Patient.

Terms and Conditions:

  1. Consent: The Patient consents to the root canal treatment, understanding its nature, potential risks, and benefits. The Clinic has provided adequate information regarding the procedure.
  2. Fees and Payments: The Patient agrees to pay the specified fees for the root canal treatment. Payment will be made according to the Clinic’s payment policies.
  3. Appointment Schedule: The Patient agrees to adhere to the scheduled appointments for the root canal treatment. Any changes or cancellations should be communica-ted to the Clinic at least [insert timeframe] in advance.
  4. Follow-up Care: The Patient acknowledges the importance of post-treatment care and agrees to follow the dentist’s instructions for proper care and maintenance after the root canal procedure.
  5. Responsibilities: The Clinic will provide professional and quality care during the root canal treatment. The Patient will cooperate and provide accurate information for the successful completion of the procedure.

Liability and Disclaimers:

  1. The Clinic will exercise due care and skill during the treatment. However, no guarantees or warranties are provided regarding the success of the root canal treatment due to the variability of individual responses.
  2. The Clinic shall not be liable for any complications arising due to non-compliance with post-treatment instructions or if the Patient fails to attend scheduled follow-up appointments.

Confidentiality:
Both parties agree to maintain the confidentiality of all information exchanged or obtained during the root canal treatment process.

Termination:
Either party may terminate this agreement in writing in the event of a breach of terms or as otherwise agreed upon between the Patient and the Clinic.

Governing Law:
This Agreement shall be governed by and construed in accordance with the laws of Philippines.

Agreement Acknowledgement:

    Clinic Representative*:

    Patient's name*:

    Date*:

    * Denotes required field