I hereby give my consent to Dr. Zoufan and his assistants to perform an initial examination prior to any definitive treatment. This consent is for evaluation only and no invasive treatment will be performed prior to discussion of proposed treatment with the doctor and trained staff.

This initial evaluation consists of, but is not limited to: examination of diagnostic radiographs and dental CT scan, pulp vitality testing, localized periodontal examination, and definitive treatment planning. I understand that in some instances, a local anesthetic (numbing) may be needed for diagnostic purposes.

I understand that diagnostic radiographs may be needed at the doctor's discretion. I also understand that the doctor may require consultation with other dental and medical professionals prior to the initiation of any treatment. I authorize Zoufan Endodontics to obtain any necessary medical history or clearance for treatment from my physician(s) and to send any necessary dental records either to those actively participating in my care or to me personally.

I understand there is a fee for initial consultation. As a courtesy, Zoufan Endodontics will submit an insurance claim on my behalf; however, I am ultimately responsible for the balance.

As to the diagnosis of nen-dental conditions, I understand that while portions of my anatomy beyond my mouth and jaw may be evident from the radiographs, that the doctors at Zoufan Endodontics are not oral or medical radiologists and so are not licensed to diagnosis or treat non-dental conditions in those area. Therefore, it may be necessary, and I acknowledge that the option has been offered to me, to have my radiographs reviewed by an oral and maxillofacial or medical radiologist for any abnormalities, asymmetries, or other non-dental pathologic conditions which might be noted in my radiographs.

By signing this form, I verify that I have read the entire form and my questions, if any, have been answered to my satisfaction.

I have received and reviewed Zoufan Endodontics’ FINANCIAL POLICY and agree to the terms stated. I understand that I am fully responsible for payment of treatment provided by this office. Further, I authorize Zoufan Endodontics to obtain and verify my insurance benefits and eligibility with my dentist(s) or dental insurance carrier, as well as to file claims to my insurance carrier on my behalf.

I have received and reviewed Zoufan Endodontics’ NOTICE OF PRIVACY PRACTICES.