Primary Dental Insurance

Secondary Dental Insurance

Payment is expected when services are rendered. For your convenience, we will prepare insurance claims for you. 

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the perioud of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

The following information is routinely provided to anyone considering treatment in our office. Although good results are expected, the possibility and nature of complication cannot be accurately anticipated and therefore, there can be no guarantee as to the results of the treatment or as to care. Although the likelihood of their occurance in extremely remote, some risks are now to be associated with dental procedures. Some are postoperative discomfort, trismus (restrictive jaw opening), numbness, infection, swelling, bleeding, discoloration, nausea, vomitting, and allergic reactions. 

I have read the preceding risks that may occur in connection with this procedure. I believe I have been given and understand sufficient information to give consent to the above treatment, and to the administration of anesthetics and medications that the staff of Hot Springs Endodontics deems necessary for the care of the patient named above. 

In the following questions, answer YES or NO, whichever applies. Your answers are for our records only, and will be considered confidental.

Do you have or have you ever had?

Are you taking any of the following?

Are you allergic or have you reacted adversely to:

The above information that I have provided is true and correct to the best of my knowledge.

Patient Consent Form for Endodontic Treatment

Endodontic treatment, otherwise known as root canal therapy, is performed to treat a tooth that might otherwise require extraction. I understand certain risks are associated with this treatment, as in all areas of dentistry. Complications may result from the use of dental instruments, drugs, and anesthetics. These may include, but are not limited to: swelling, sensitivity, bleeding, pain, infection, numbness which usually lasts for a few hours but may rarely be permanent, reaction to shots, changes in biting and the way the teeth fit together, muscle cramps, joint difficulties, loosening of teeth, damage to other teeth, pain to the ear, neck, and head, nausea, vomitting, allergic reactions, delayed healing, sinus perforations, and treatment failures. During instrumentation of the tooth, a procedural error may occur. Although this occurs rarely, such an occurance could cause the failure of the root canal, loss of the tooth, or possibly the need for a new crown or restoration. 

I understand that I may have to take certain medications while this therapy is being performed which may result in allergic reactions, drowsiness, or lack of awareness and coordination. I understand that I am not to use alcohol, tranquilizers, or sedatives while on medication for my treatment unless otherwise instructed by my doctor. I understand that I am not to drive or operate a car, or other machines, while taking certain medication as indicated by my doctor. 

I understand that other treatment choices include no treatment or extraction of my tooth. Risks of these choices include but are not limited to pain, swelling, loss of teeth, and/or infection to other areas of the body.

Temporary fillings are often placed in the tooth after root canal treatment. I understand that upon completion of the root canal therapy, it is my responsibility to have a final restoration (filling, crown, etc) placed on the endodontically treated tooth. Future decay or fracture is possible.

If I have taken or am taking bisphosphonates (Fosamax, Boniva, Actonel, Zometa, Aredia, and others) for treatment of osteopenia, osteoporosis, bone cancer, or any other reason, I understand that there may be a risk of a very rare complication known as osteonecrosis of the jaw bone, commonly referred to as "dead jaw".

Any and all of my questions have been clearly answered. I also understand that any questions have been clearly answered. I also understand that any questions that I might have during the treatment will be answered when I ask them. I, the undersigned, being the patient (parent or guardian of a minor patient) have read and understand this form and consent to endodontic therapy on the involved tooth or teeth.

I acknowledge I have received a copy of this office's Notice of Privacy Practices.