Patient Information Form

Please list any medication(s) you are taking (including natural, herbal, or homeopathic products) or you may upload a file containing the list below. Be sure to include Medication Name, Dosage and Frequency.

Payment Terms

ln most cases the duration of the endodontist-patient is short term. Due to this, and the high degree of responsibility we assume with your care, full payment is required by the completion of your treatment.

These fees vary depending the tooth involved and the complexity of the case. There may be additional charges for re-treatment, extra canals, curved roots or unusually complex cases. Please feel free to ask any questions you have in regards to payment, however we do ask you read and understand the following payment policies.

Range of Fees

Consultation/Examination/CBCT (3D) Scan                $185-$535.00

                                                                        (Consult $185 CT scan $450)

Root Canal Therapy                                                 $1295 - $1675

Root Canal Retreatment                                           $1495 - $1875

*The range of fee depends on the complexity and difficulty of the tooth 

PRIVATE PAYMENT: We require full payment at the time of your treatment is rendered. For your convenience we offer the following options:

*Subject to credit approval. Please inquire for additional information.

DENTAL INSURANCE: We will bill your insurance company a complimentary service, however we do as you your require the estimated co-payment from you by the end of treatment. We will call your insurance carrierfor your estimated co-payment amount, though we try to be as accurate as possible it not always an exact amount and may differ after insurance pays. Please remember that insurance is considered method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Ultimately you will be responsible for any fees not covered by your dental insurance company. Any remaining balance is due within 30 days.

I acknowledge I have read and understood the above information.

Root canal treatment is an attempt to retain a tooth, which may otherwise require extraction, Although root canal therapy has a high degree of success, it cannot be guaranteed. Once an appointment is made, please remember this time is reserved for you. We require at least 24 hour notice if cancellation is absolutely necessary, otherwise a cancellation charge may apply.

I certify that I have read and I understand the questions above, I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibililty to pay and deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney's fees, and court costs.

This signature on file is my authorization of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Security of your Personal Information

West Valley Endodontics Group secures your personal information from unauthorized access, use, or disclosure. We use the following methods for this purpose:SSL Protocol – When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use ofencryption, such as the Secure Sockets Layer (SSL) protocol.Jotform HIPAA Compliance – – all forms on this website are encrypted and stored on a secure server meeting HI PAA complianceguidelines for your privacy.We strive to take appropriate security measures to protect against unauthorized access to or alteration of your personal information. Unfortunately, no data transmission over the Internet or any wireless network can be guaranteed to be 100% secure. As a result, while we strive to protect your personal information, you acknowledge that: (a) there are security and privacy limitations inherent to the Internet which are beyond our control; and (b) security, integrity; and privacy of any and all information and data exchanged between you and us through this Site cannot be guaranteed.