Mid-Florida Endodontics

Main Header

Patient Information

Prefix

Mr. Mrs. Ms. Dr.

Name

Nickname

Primary Language / translation needs

Sex

Male Female

Birth Date / Age / Soc. Sec. #

Address

City / State / Zip

Home / Cell Phone

Work Phone / Employer

Emergency Contact / Tel.

General Dentist

Tel. / If Greenberg or Coast, which location

Who will be responsible for your account?

Who will be responsible for your account?

Self (If self, skip to next section) Spouse Parent Other

Name

Soc. Sec. #

Address

City / State / Zip

Home / Cell Phone

Work Phone / Employer

Pharmacy Information

Pharmacy Name / Tel.

Pharmacy Address

City / State / Zip

Dental Insurance Information

Primary Insurance Company

DMO/HMO PPO DELTA CARE

Tel. / Subscriber ID #

Group # / Name

(If other than patient)

Insured Party's Name

Relation

Address

City / State / Zip

Birth Date / Soc. Sec. #

Tel. / Employer

Medical History

Has your physician/cardiologist instructed you to premedicate with antibiotics prior to a dental appointment?

Yes No

If Yes to any, please explain:

Are you currently Pregnant or Nursing:

Yes No

Medications presently taking (bone density medications, bisphosphonates, blood thinners, vitamins, supplements, others):

Allergic to any drugs or medications & describe reaction to it:

I certify that the above information is correct:

Patient Signature (or guardian of a minor)

Click to Sign

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

Acknowledgement of Receipt of Notice of Privacy Practices

Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), you have certain rights to privacy regarding your protected health information. You understand that this information
can and will be used to:

• Conduct, plan and direct your treatment and follow-up among the health care providers who may be involved in that treatment directly or indirectly
• Obtain payment from third-party payers
• Conduct normal health care operations such as the business aspects of running the practice on a daily basis

By signing this you acknowledge you have received, read, and understand our Notice of Privacy Practices containing a more complete description of the uses and
disclosures of my protected health information. You understand we reserve the right to change our privacy practices as described in the Notice of Privacy Practices.
Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

For Mid-Florida Endodontics locations in Longwood, Maitland, Kissimmee, Waterford, Winter Garden, Dr. Phillips, Orange City, & Daytona Beach:
Contact Person: Office Manager Telephone: 407-581-9515 Fax: 407-581-9520 Address: 12301 Lake Underhill Rd. Suite 104, Orlando, FL 32828

Right to Restrict: You may request in writing that we restrict how your private information is used or disclosed to carry out treatment, payment, or health
care options. You also understand we are not required to agree to your requested restrictions, but if we do agree then we are bound to abide by such restrictions.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person
listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation,
and that we may decline to treat you or to continue treating you if you revoke this Consent.
Signature:

Click to Sign

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

Name:

(specify if parent/guardian)

Yes No

*You May Refuse to Sign This Acknowledgement

Informed Consent for Endodontic Treatment

You have been referred to our specialty office because you may need to receive endodontic therapy. The need for this therapy is mostly due to trauma (often from a cavity, large restoration, or fracture) to your tooth, which has compromised the health of the pulp tissue. Endodontic (root canal) therapy is performed to relieve your current symptoms and save a tooth which might otherwise need to be removed. The therapy is accomplished by conventional endodontic therapy (removal of the nerve tissue and the sealing of the space that is created in the canal in order to relieve or prevent infection in the root of your tooth), or when needed, endodontic surgery. We do not do oral cancer screenings.

We would like our patients to be informed about the various procedures and risks involved in endodontic therapy/surgery versus other treatment choices. You will be required to sign this consent prior to your evaluation, however it does not commit to you opting for treatment. It serves to acknowledge that you may ask any questions and have been informed and understand the following:

RISKS OF ANY DENTAL PROCEDURE: Included, but not limited to, are: allergic reactions or complications from the methods and use of dental instruments, dental materials, medications and injections. Complications may include swelling, bruising, sensitivity, bleeding, pain, itching, infection, tooth discoloration, restricted jaw opening, delayed healing, changes in the occlusion (biting), jaw pain or restricted opening, facial/neck muscle cramps and spasms, and numbness or tingling in the face and mouth. On infrequent occasions, development of an abscess, loosening of teeth, referred pain to the ear, neck or head, nausea, or sinus perforations may occur.

RISKS MORE SPECIFIC TO ENDODONTIC THERAPY AND SURGERY: Included, but limited to, are: the possibility of instruments breaking within the root canals, the possibility of broken instruments or debris within or surrounding the root, perforations (extra opening) of the crown or root of the tooth, damage to bridges, existing fillings, crowns, porcelain veneers, loss of tooth structure, cracked teeth, injury to soft tissues or nerves near the tooth, and small root fragments remaining. If it is necessary to access the root through an existing crown, you may require a new crown. Your general dentist will determine if a new crown is required. During the procedure, complications may become apparent which make treatment impossible, or which may require dental surgery or extraction (removal of the affected tooth). These complications include inability to access to the tooth needing treatment, blocked canals due to fillings or prior treatment, curved or narrow canals, natural calcifications, broken instruments, periodontal disease, resorptive defects, and fractures (cracks) of the teeth.

MEDICATIONS: Prescription medications may cause ineffectiveness of birth control pills, drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol or other drugs). It is not advisable to operate any vehicle or hazardous devices until you have recovered from their effects.

OTHER TREATMENT CHOICES: These include no treatment, waiting for more definite development of symptoms, or tooth extraction. All of these choices, and the choice not to complete the root canal treatment once it has begun, carry risks of their own including, but not limited to: severe pain, infection and swelling, cyst formation, systemic disease, and loss of this tooth and possibly other teeth. Extraction frequently needs to be followed by a bridge, partial denture, or an implant to prevent shifting of the other teeth so that there will be an even distribution of the forces during chewing, and to keep a full appearance of the face. All these restorations are at an additional cost to the cost of extraction.

Patient Initials

Click to Sign

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

INSURANCE: As a courtesy to you, we participate in many insurance plans, but our professional services are rendered and charged to you, not your insurance company. Your insurance policy is a contract between you/your employer/your insurance company, but not our office. However, if insurance information is provided prior to your treatment and verification is obtained, we will accept assignment for the insurance portion of the benefits. Before treatment is performed, we collect payment of any deductible amount, co-pay, or other estimated amount not covered by your insurance company. Any portion of the fee not covered by your insurance is your responsibility. Our office will not enter into a dispute with your insurance company over any claim. All fees charged via attempts to collect any patient portion will be the financial responsibility of the patient or guardian. It is your responsibility to file any medical claims, workman’s comp, secondary insurance, COBRA, or government/military insurance.

*Please be aware our offices charge a 3% credit card processing fee for all credit card payments*

Although the endodontic therapy performed will be performed in a manner which will minimize and avoid risks and has ahigh degree of clinical success, it is still a biological procedure and cannot be guaranteed. Various factors that cannot be controlled contribute to the success of the therapy, which include, but are not limited to: your general health, your healing capacity or resistance to infection, adequate gum attachment and bone support, the anatomy, condition and location of the roots, habitual clenching and grinding, the force with which you bite and a fracture of the treated tooth. If we detect a fracture in a tooth and still recommend treatment, be aware that in spite of treatment some cracks may continue to progress, ultimately resulting in loss of the tooth. However, treating the cracked tooth is still important because it will relieve pain and reduce the likelihood that the crack will worsen.

Rarely, a tooth that has had endodontic therapy may not relieve your pain and symptoms totally, and may require retreatment, surgery, even extraction, or treatment of another tooth. There will be a full charge for all completed cases, regardless of success or failure. If a treatment cannot be completed due to a complication, there will be a charge for all procedures performed up to that point.

It is your responsibility to seek attention should any undue circumstances occur postoperatively and diligently follow any preoperative and postoperative instructions given to you. UPON COMPLETION OF THE ENDODONTIC PROCEDURE, YOU MUST PROMPTLY (in no case longer than 30 days) RETURN TO YOUR GENERAL DENTIST FOR PERMANENT RESTORATION OF THE TOOTH, (the cost of which is not included in our fee).

I have read, acknowledge and understand the content of this document. I consent to allow and authorize the dentist and/or his staff to perform any examinations, diagnostic procedures, and render any treatment or medications necessary or advisable to my dental condition as it stands now or as it arises during treatment.

Patient Signature (or guardian of a minor)

Click to Sign

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

truForm by PBHS

Mid-Florida Endodontics

Main Header

Demographic Information

Patient Information

Who will be responsible for your account?

Pharmacy Information

Insurance Information

Dental Insurance Information

Medical History

Have you ever had or do you currently have:

Medical History

Click to Sign

Privacy Practices Acknowledgement

Acknowledgement of Receipt of Notice of Privacy Practices

Click to Sign

Endodontic Treatment Consent

Informed Consent for Endodontic Treatment

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.

Mid-Florida Endodontics

Main Header

Demographic Information

Patient Information

Who will be responsible for your account?

Pharmacy Information

Insurance Information

Dental Insurance Information

Medical History

Have you ever had or do you currently have:

Medical History

Click to Sign

Privacy Practices Acknowledgement

Acknowledgement of Receipt of Notice of Privacy Practices

Click to Sign

Endodontic Treatment Consent

Informed Consent for Endodontic Treatment

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.