Patient Registration Form (Minor)

Completion of this online form may save the patient time before their appointment. If you have any difficulty completing this form please note that you may fill it out in our office before your appointment at which time our staff will be available for assistance.

IMPORTANT: All fields on this form are required to be filled out to make sure our records are accurate. If a question does not apply to you or you prefer not to provide the information please enter "N/A" to complete the form.

Patient Registration
At which of our locations does the patient plan to be treated?

I understand Root Canal treatment 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 biologial procedure, so it cannot be guaranteed. Occasionally, a tooth which has had Root Canal therapy may require retreatment, surgery, or even extraction.

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

The preferred payment is Fee for Service. We accept the assignment of insurance benefits as a payment option and service to our patients only under certain conditions. An estimate of your portion not covered by insurance is due at the time of treatment. An estimate of benefits is RARELY exact, and disputes concerning coverage, usual & customary fee schedules, etc. are strictly between you and your insurance company. Your account remains strictly your responsibility. Statements are prepared when insurance reimbursement is received, and any remaining balance is due and payable upon receipt. If any conditions are not met, or when there is no insurance coverage, payment in full is expected at the time treatment is rendered. Unpaid balances on your account are subject to a finance charge of 1.5% per month (18% APR) after 90 days.

I authorize my insurance carrier (if patient is covered by dental insurance) to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process a dental insurance claim.

(Type your full name below to sign electronically)

Medical History
Is patient presently under the care of physician?
Has the patient been seriously ill within the past 5 years?
Has the patient had a physical examination within the past 2 years?
Is the patient taking any medication at the present time? (Please include any over the counter medication - including Tylenol, aspirin, etc.)
Are there any ALLERGIES to any drugs or medications?
Has the patient ever had or been treated for? (Please check)
Have there been any transplants, implants or artificial organs?
Has your physician recommended antibiotic premedication?
Female Only: Is she pregnant?
Dental Information
Are there any special concerns regarding the dental treatment?
Would the patient like nitrous oxide (laughing gas) during their treatment? (Additional charge)
By typing your full name below to electronically sign, you verify that the information you have filled out above is accurate.
Endodontic Consent and Information Form

Endodontic Root Canal Therapy, Endodontic Surgery, Anesthetics, and Medications

We would like our patients to be informed about the various procedures involved in endodontic therapy and have their consent before starting treatment. Endodontic (root canal) therapy is performed in order to save a tooth which otherwise might need to be removed. This is accomplished by conservative root canal therapy, or when needed, endodontic surgery. The following discusses possible risks that may occur from endodontic treatment, and other treatment choices.

RISKS: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections. These complications include: swelling; sensitivity; bleeding; pain; infection; numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth, which is transient but on infrequent occasions may be permanent; reaction to injections; changes in occlusion (biting); jaw muscle cramps and spasms; temporomandibular (jaw) joint difficulty; loosening of teeth; referred pain to ear, neck and head; nausea; vomiting; allergic reactions; delayed healing, sinus perforations and treatment failure.

RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: The risks include the possibility of instruments broken within the root of the tooth; damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals, and cracked teeth. During treatment complications may be discovered which make treatment impossible, or which may require dental surgery. These complications may include: blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), splits or fractures of the teeth.

MEDICATIONS: Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any vehicle or hazardous device until recovered from their effects.

OTHER TREATMENT CHOICES: These include no treatment, waiting for more definite development of symptoms, tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth and infection to other areas.

CONSENT: I, the undersigned, being the patient (parent or guardian of minor patient) consent to the performing of procedures decided upon to be necessary or advisable in the opinion of the doctor. I also understand that upon completion of root canal therapy in this office I shall return to my general family dentist for a permanent restoration of the tooth involved, such as a crown, cap, jacket, or silver filling.

I understand that root canal treatment is an attempt to save a tooth which may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally a tooth which has had root canal therapy may require retreatment, surgery or even extraction.

(Type your full name below to sign electronically)

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