Welcome to Our Office!   Date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec     *Indicates Required Fields.

Patient Information

Please Choose: Ms  Mr  Mrs  Dr  Other

Last Name* First Name* MI Name Preference

Street Address* City* State* Zip* AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Home Phone* Work Phone Cell Phone Email Address

Member ID #* Date of Birth* Sex* Spouse Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,  M/F

Employer Employer Address

General Dentist* Physician Whom may we thank for referring you?*

Full Time Student? School:

In Case of Emergency Contact:* Name* Home Phone:* Work Phone:

Medical History

Please check Y for “yes” or N for “no” for any of the following which may apply to you now or in the past:*

Y N   Y N   Y N   Congenital Heart Lesions Artificial Heart Valve Heart Murmur Heart Disease or Attack Pain in Jaw Joints Heart Surgery Epilepsy or Seizures Heart Pacemaker Artificial Joint High Blood Pressure Rheumatic Fever Tuberculosis Mitral Valve Prolapse Thyroid Disease HIV Positive Hepatitis A, B, or C Angina Pectoris Diabetes Bleeding Disorder Drug Addiction

Have you ever taken Bisphosphonates?* Yes/No (i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec)

Any other diseases or problems?

Have you ever had an unusual reaction to latex, an anesthetic, or drug such as Penicillin, Erythromycin, Novacaine, Codeine, Aspirin, Sulfa, or any other medications?*  Yes / No If yes, please explain:

What medications are you taking at present?

Have you taken Aspirin or Ibuprofen in the last 72 hours?* Yes / No If yes: Aspirin?  Ibuprofen? How many?

Women - Are you pregnant? Yes / No If yes, what month?

THE PURPOSE of endodontic treatment or root canal treatment is to save the tooth rather than remove it.  Although treatment has a high degree of success, it cannot be guaranteed.  Occasionally, a tooth that has had a root canal treatment may require re-treatment, surgery or even extraction. Treatment is usually a non-surgical procedure, but in some cases, a surgical approach is necessary.  Before any treatment is begun the reason(s) will be explained, including alternative modes of therapy.  Occasionally, pre-medication may be indicated.  This will be discussed in advance.

PLEASE NOTE: The fee will not include a permanent filling or crown on the tooth. You must return to your general dentist to have that treatment completed.

I consent to necessary treatment and authorize the release of any information needed for further treatment.*

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Signature of Patient (Custodial Parent/Guardian of Minor)* Date

Please verify my insurance.(*Please fill out all insurance information) Contact me regarding my insurance. I do not have insurance.

Primary Dental Insurance

Name of Insured Person (Employee): Relationship to Patient:

Member ID: Date of Birth (m/dd/yyyy): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,

Employer/Retired From: Length of Employment:

Insurance Company: Group #: Insurance Phone:

Address: City: State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

Secondary Dental Insurance

Name of Insured Person (Employee): Relationship to Patient:

Member ID: Date of Birth (m/dd/yyyy): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ,

Insurance Company: Group #: Insurance Phone:

Address: City: State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

I hereby authorize the provider to file my insurance and benefits to be paid directly to the provider. I also understand that when my particular insurance is filed: I authorize the release of any information related to my claim to my insurance company. I am ultimately responsible for the balance on my account for any professional services rendered regardless of the amount my insurance pays toward my account. We ask that patients with insurance pay estimated portion of the cost of treatment; at the time service is received. Any balance not paid by my insurance will be due within two weeks of the statement date, a LATE FEE and/or SIMPLE INTEREST CHARGE may be added to the account. The INTEREST CHARGE will be a periodic rate of 1.5% per month, which is an ANNUAL PERCENTAGE RATE of 18% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection on this account. If patient is under the age of 18 years old, please complete the following: Responsible Party: SSN: Street Address City State Zip AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Home Phone Work Phone Relationship to Patient

I understand that I am ultimately responsible for fees incurred at the time of service.* Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Signature of Patient (Custodial Parent/Guardian of Minor)* Date