I
First Name
Last Name
(parent or guardian if minor) consent to procedures necessary or advisable in the opinion of the doctor. I understand that root canal treatment is an attempt to save a tooth, which may otherwise require extraction. Root canals are performed with a high degree of success. A root canal can be required due to trauma, decay, infection, or pain. Occasionally a tooth, which has had a root canal, may require retreatment, corrective surgery, or extraction. There is no guarantee that treatment will be successful, despite the best treatment and intentions.COMPLETION OF RESTORATION: Upon completion of a root canal, it is necessary for you to return to your dentist for a final restoration of the tooth involved, such as a crown or other restoration. Failure to restore the opening in the tooth, could result in failure of the root canal.RISKS TO TREATMENT: There are inherent risks to any procedure. Risks may include, but are not limited to reactions to anesthetics, pain, infection, numbness and tingling in the lip, tongue, chin, gums (which is usually temporary), but may be permanent. Changes in the way your teeth meet, jaw muscle cramps or spasms, trismus (jaw locking), TMJ joint tenderness (jaw joint), loosening of teeth, pain in ear, neck and head, nausea, allergic reactions, continued pain, sinus issues, delayed healing, and treatment failure.MEDICATIONS: Prescribed medications and drugs may cause drowsiness and lack of co-ordination. You should not operate any vehicle or hazardous device while taking these medications. Should any reaction to medications take place, please notify the treating doctor.INCOMPLETE TREATMENT: If the doctor determines during the procedure that the tooth cannot be saved, a fee will be charged for incomplete treatment.MEDICAL INSURANCE: Our endodontic practice does not file workman’s comp, medical or accident insurance. We will happily provide all documentation necessarily needed to file a claim.RADIOGRAPHS AND CONE BEAM CT SCAN: The need for dental x-rays depends on each patient’s individual dental needs. The doctor will order needed digital x-rays and Cone Beam CT scan as indicated. Dental x-rays & CT scan produce low levels of radiation and are considered safe for diagnostic purposes.HIPAA : I acknowledge that this office’s notice of privacy practices is available to me and posted for my review.INSURANCE/FINANCIAL: I authorize the release of any information relating to all claims and hereby direct benefits payable to Endodontic Associates of Irving. My co-payment is due at the initiation of treatment. Any balance not paid by insurance is my responsibility. I understand that this office will accept an insurance benefit payment with the co-payment due at the time of service. I understand insurance co-payment quoted at the time of service is only an estimate. A balance may remain after dental insurance payment is made. I also understand that I am fully responsible for the entire balance for the services provided after the insurance benefits have been paid. You are responsible for payment of services provided and insurance carriers do not guarantee payment. Payment options are cash/check, credit or debit cards and CareCredit.CALLS AND TEXT MESSAGES: I hereby consent to receive auto dialed and/or pre-recorded calls and related texts in regards to appointments, account balances, collections and marketing from third party companies to cell phone number(s) provided above. I understand that consent is not a condition of purchase or services rendered.STATEMENT OF ACCEPTANCE: I hereby state that I have read and understand this consent for treatment. I have had the opportunity to ask questions and have them answered. I fully understand the consent form. I give my permission to record my procedure, take digital photos as necessary to complete my medical record and/or for educational purposes. All medical records will be kept strictly confidential.PRIVACY PRACTICES ARE POSTED AT THE FRONT DESK AS REQUIRED BY FEDERAL AND STATE LAW. THESE PRACTICES DESCRIBE HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. IF YOU WOULD LIKE A COPY, PLEASE ASK US, THIS IS YOUR RIGHT. YOU MAY ALSO GO TO WWW.EAOFIRVING.COM TO REVIEW OR PRINT A COPY OF THESE DISCLOSURES.
Signature of patient (Parent or Guardian if Minor)
