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www.cwendo.com
Tel: 804-501-0501

PATIENT INFORMATION

Referred by

General Dentist

Tooth #

Patient

DOB/SSN

Patient Sex

MALE FEMALE

CHILD*

Street Address

City/State/Zip Code

Marital Status

SINGLE MARRIED DIVORCED WIDOWED

Phone Numbers

Email Address

Employer

In case of an emergency, please provide information for the nearest relative or designated contact person:

Name

Relationship/Phone #

RESPONSIBLE PARTY (to be completed if the patient is a minor or not financially responsible for the account)

Name of Responsible Party

Relationship to Patient

Date of Birth/SSN/Phone Number

Address

City/State/Zip Code

For Women

Are you pregnant?

Yes No

Are you nursing?

Yes No

Do you suspect you are pregnant?

Yes No

Are you taking birth control pills?

Yes No

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his staff at Commonwealth Endodontics responsible for any errors or omissions that I may have made in the completion of this form.

Signature of patient or legal designate

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Date:-------------

ENDODONTIC CONSENT & INFORMATION FORM

Endodontic treatment (root canal therapy) involves cleaning, shaping, disinfecting, and filling the root canal(s) of a damaged or diseased tooth. The canal is the space inside the root, which contains developmental tissue. Although this tissue is removed, live cells remain on the outside of the root, and the body continues to recognize the tooth as alive after treatment. Multiple visits may be necessary to complete treatment.

This form serves as your consent for a Commonwealth Endodontics provider to evaluate and/or treat you as a patient. Treatment may not be initiated today. However, it is important that you are informed of the procedure(s) being considered and all potential outcomes, whether treatment occurs on this visit. Please review the following:

1.   Success Rate & Limitations
Root canal therapy has a 90â€“95% success rate; retreatment success is 80â€“85%. Endodontics is not an exact science, and no guarantee of treatment success can be made. Additional treatment or extraction may be needed if post-treatment issues arise.

2.   Previous Treatment
Endodontic treatment started or completed at other offices may have different outcomes than expected under optimal conditions.

3.   Restoration Is Required
After treatment, contact your general dentist promptly to schedule permanent restoration. Your restorative dentist will place either a filling or a crown on your tooth. The filling that we place for you is only temporary.

4.   Possible Complications
Risks include: Swelling, soreness, infection, trismus (limited opening), tissue discoloration, tooth fracture, instrument separation, root perforation, under- or overfilling of canals, sinus involvement, damage to existing dental work, blocked or curved canals, resorption, or calcifications.

Local anesthetic is used to numb the area. Though rare, complications may include swelling, bleeding, infection, prolonged numbness or tingling (possibly permanent), muscle cramps, trismus, rapid heartbeat, and allergic reactions.

5.   Existing Restorations (Crowns, Bridges, Inlays/Onlays)
These restorations may need replacement after treatment if decay is present or if the restoration is compromised during access. In most cases (95%), treatment can be completed through existing restorations without issue. However, if damage occurs, the patient is responsible for replacement costs. Commonwealth Endodontics is not responsible for fabrication or payment of new restorations.

Note: All services at Commonwealth Endodontics, including root canal therapy, retreatment, and apicoectomy, are non-refundable.

By signing below, I acknowledge and accept the above risks. I consent to being evaluated by a provider at Commonwealth Endodontics and understand that if I accept the proposed treatment plan and choose to proceed, I am giving my consent for endodontic treatment to be performed, including the use of necessary anesthetics, medications, and services deemed necessary. Endodontic treatment follows accepted clinical practices, and digital images may be taken before, during, and after treatment. I also authorize the release of my dental records to my dentist and/or insurance company.

Signature of patient or legal designate

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Date:-------------

INSURANCE, PAYMENT & CONDUCT POLICIES

At Commonwealth Endodontics, we are committed to delivering exceptional care through a safe, respectful, and professional environment. To support this, we ask for your understanding and cooperation with the following policies.

Patient Code of Conduct
Patients and their guests are expected to treat staff and others with courtesy, communicate respectfully, and follow all practice policies. Verbal abuse, threats, profanity, or disruptive behavior will not be tolerated and may result in immediate dismissal from the practice. Dismissed patients must arrange for their own future care. If you have concerns, please speak with our team respectfully – we’re here to help

FINANCIAL AGREEMENT & ACKNOWLEDGEMENT

Please read and select the section that applies to your situation.

Initial

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Date:-------------

No dental insurance: I understand that full payment is due on the date of service for all services rendered.

Initial

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Date:-------------

With dental insurance: I understand CWE will file claims on my behalf. I am responsible for the estimated copayments at the time of service and for any balance not covered by insurance.

As a courtesy, CWE verifies insurance coverage and provides an estimate before your visit. This is not a guarantee of payment. The insurance contract is between the patient, their employer, and the insurer - CWE is not a party to it. Any remaining balance after insurance is processed will be billed. Overpayments will be refunded by check.

Please read and initial to acknowledge the following:

Initial

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Date:-------------

If a tooth is deemed unsalvageable once treatment has begun, an inoperable fee of $537 will replace the full cost of your treatment and is due the same day. Insurance may not cover this service or may reimburse it at a lower rate than the planned treatment.

Additional Payment Terms: I understand that if I do not pay on time, my account may be sent to collections. I will be responsible for all related costs, including billing, attorney, and court fees. Accounts unpaid after three statements may incur a $200 administrative process fee. Returned checks are subject to a $40 fee.

I have read and fully understand the above insurance, payment, and conduct policies.

Signature of patient or legal designate

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Date:-------------

Consent to Use Dental Radiographs and/or Digital Images and Reviews

To comply with the Health Insurance Portability and Accountability Act (HIPAA), we need your permission to use certain materials. Your privacy is important to us, and we value your right to control how your information is used.

Patient Information

Name

Date of Service

CONSENT OPTIONS (Please select YES or NO for each option below):

1. Use of Dental Radiographs & Digital Images
Do you consent to allow Commonwealth Endodontics to use dental radiographs and/or digital images of your teeth for:
• Dental Records
• Research and Education (e.g., lectures, publications)
• Marketing (e.g., website, social media)

YES, I consent NO, I do not consent

2. Use Of Patient Reviews
Do you consent to allow Commonwealth Endodontics to use your review for marketing purposes (e.g., social media, website) Reviews will exclude personal health information.

YES, I consent NO, I do not consent

I further understand that if the dental radiographs, digital images, and/or reviews are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these dental radiographs, digital images and/or reviews. I understand I can revoke my permission at any time by notifying Commonwealth Endodontics in writing

Signature (Patient/Guardian)

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Date:-------------

Thank you for helping us improve patient care and share experiences while respecting your privacy!

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT**

Please click here to view the Notice of Privacy Practices

, have received a copy of this office’s Notice of Privacy Practices.

Signature

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Date:-------------

In accordance with HIPAA privacy regulations, please list any friends or family members you authorize us to share your protected health information (PHI) with:

NAME

RELATIONSHIP/PHONE #

NAME

RELATIONSHIP/PHONE #

NAME

RELATIONSHIP/PHONE #

NAME

RELATIONSHIP/PHONE #

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Patient Information

PATIENT INFORMATION

RESPONSIBLE PARTY (to be completed if the patient is a minor or not financially responsible for the account)

Medical History

MEDICAL HISTORY

Medical History - Please check all that apply

For Women

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Endodontic Consent & Information Form

ENDODONTIC CONSENT & INFORMATION FORM

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INSURANCE, PAYMENT & CONDUCT POLICIES

INSURANCE, PAYMENT & CONDUCT POLICIES

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Consent to Use Dental Radiographs and/or Digital Images

Consent to Use Dental Radiographs and/or Digital Images and Reviews

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Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Symptoms Questionnaire

Symptoms Questionnaire

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Main Header

Patient Information

PATIENT INFORMATION

RESPONSIBLE PARTY (to be completed if the patient is a minor or not financially responsible for the account)

Medical History

MEDICAL HISTORY

Medical History - Please check all that apply

For Women

Click to Sign

Endodontic Consent & Information Form

ENDODONTIC CONSENT & INFORMATION FORM

Click to Sign

INSURANCE, PAYMENT & CONDUCT POLICIES

INSURANCE, PAYMENT & CONDUCT POLICIES

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Consent to Use Dental Radiographs and/or Digital Images

Consent to Use Dental Radiographs and/or Digital Images and Reviews

Click to Sign

Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click to Sign

Symptoms Questionnaire

Symptoms Questionnaire

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