Patient Information

PATIENT INFORMATION

Please Fill Out
Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth

MonthDayYear
Date
Patient Social Security Number*
Please enter 9 digit number
Employer (if minor, Parent’s Employer)*
Email Address*
example@example.com
Cell Phone*

Area CodePhone Number
Business Phone

Area CodePhone Number
Home Phone*

Area CodePhone Number
Name of Spouse (or parent’s if minor)*

First NameLast Name
Spouse’s (parent’s) Birth Date*

MonthDayYear
Date
Spouse’s (parent’s) SSN*
Please enter 9 digit number
Spouse’s (parent’s) Employer*
Person to Contact in Case of Emergency*

PrefixFirst NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*

Area CodePhone Number
Physician*
Physician Phone Number*

Area CodePhone Number
Referring Dentist*
Referring Dentist Phone Number*

Area CodePhone Number
Upload Referral

Browse Files

Cancelof
Dental Insurance

YesNo
Name of Insured/Subscriber

First NameLast Name
Patient's Relationship to Insurance Subscriber

SelfSpouseChild
Subscriber’s DOB

MonthDayYear
Date
Policy / ID Number
Name of Insurance Company
Phone Number

Area CodePhone Number
Group Number
Insurance Card Upload

Browse Files

Cancelof
INFORMED CONSENT
This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable as a corollary to the planned endodontic therapy performed by Endodontic Associates and any assistant the may require. I agree to the use of local anesthesia sedation, and/or analgesia, depending upon the judgement of the endodontist. Complications of root canal therapy and anesthesia may include swelling, discomfort, infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent.

I understand root canal therapy is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require retreatment, surgery, or even extraction.

I understand that Endodontic Associates is not financially responsible to any damages to existing restorations. which include but are not limited to crowns and bridges. During the procedure the restoration could fracture, become loose, or come off completely and will necessitate to be replaced.

I also understand that only the root canal therapy is to be performed at this office. The permanent (outside) restoration (filling, onlay, crown, etc.) will be done by my regular dentist.

I understand that medications for pain and sedation may cause drowsiness which can be increased by the use of alcohol or other drugs. I will avoid operating any vehicle or hazardous devices while taking such medications. I further understand that certain medications may cause hives and intestinal problems and, if any of these reactions occur, I am to call the doctor immediately. I understand that it is my responsibil- ity to report any changes in my medical history.

All reasonable collection and/or legal costs required to collect fees due Endodontic Associates will be borne by the undersigned. ALL SIGNATURES MUST BE BY PARENT OR GUARDIAN IF PATIENT IS 18 YEARS OR YOUNGER.
Name

First NameLast Name
Date

MonthDayYear
Date

FINANCIAL POLICY
As specialists in the practice of endodontics (root canal therapy), we are committed to providing you with the highest level of care. Unlike other dental services, our treatment is usually completed in one or two visits. Therefore, payment for services rendered is expected when your treatment is completed. If we are able to complete root canal therapy in one visit, the fee for that service is due at that time, if you are required to return to our office for a second visit in order to complete your root canal, payment for the entire treatment may be divided equally between the visits.

If you provide our office with complete dental insurance information, we will gladly inquire on your behalf to verify what benefits may be applied to your fee for our services. If your insurance benefits entitle you to a reduced fee or provide for payment to our office (except for deductible or co-payment), your portion of the balance is expected at the time of service. Our office will then submit your claim to your insurance company on your behalf for reimbursement. All co-payments are estimates until payment is received from the insurance company, any portion not covered will be the patient's responsibility. We are not responsible for any misquotes by either our office or your insurance company. Please keep in mind that dental insurance is a contract between you and your insurance company. Therefore, if we do not receive payment from your insurance company within 30 days, the unpaid balance of your account becomes your responsibility. We will assess a monthly late fee of 1.5% on any outstanding accounts.

A 33% collection and/or legal fee(s) required to collect fees due Endodontic Associates will be borne by the undersigned.

We understand that occasional errors may occur in the processing of insurance claims. If you believe that an error regarding your account has occurred, please do not hesitate to contact our office. We will make every effort to rectify the problem in the timeliest manner possible. Your referral to our office indicates the confidence that your general dentist has in an for providing you with the best of care possible for this type of dental cervice. It is important to realize that your general dentist may participate with insurance companies other than those with whom we participate.

Your signature below indicates that you have read this statement and that you understand your responsibilities regarding payment prior to the initiation of any treatment by the doctors in our practice.
Print Name

First NameLast Name
Date*

MonthDayYear
Date

PATIENT CONSENT FORM
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.

I understand that this information can and will be used to:
• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Please use the space provided to list the people to whom you give written authorizationion for us to disclose your health and financial information to:
Spouse/Significant Other:

First NameLast Name
Other

First NameLast NameRelationship
Family Member

First NameLast NameRelationship
On Date*

MonthDayYear
Date
Print Patient Name:*

First NameLast Name
Relationship to Patient*
Signature*

Clear
Should be Empty:

PATIENT INFORMATION

INFORMED CONSENT

MEDICAL HEALTH QUESTIONNAIRE

FINANCIAL POLICY

PATIENT CONSENT FORM