Southside Endodontics Patient Registration

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Patient Information

Name

Preferred Name

Address

City/State/ZIP

Phone Number

Preferred method of contact

Sex

Male Female Other

Birth Date /Social Security Number

Employer / Occupation

Business Address

City/State/Zip

In Case of Emergency

Who should be notified?

Relationship/Phone

Medications & Allergies

Please list all medications you currently take (including non-prescription)

Please list any medication or food allergies:

Are you allergic to latex?

Are you allergic to bleach?

Have you been advised to take a pre-medication prior to dental treatment?

Are you currently taking, or have you previously taken bisphosphonate or anti-cancer medications such
as Actonel (risedronic acid), Boniva (ibandronic acid), Fosamax (alendronic acid), or Zometa
(zolendronic acid), Prolia (denosumab), or Avastin (bevacizumab)?

Physician's name/Phone

This section is for women only

Are you pregnant?

If so, name of OB/GYN/ Phone

Nursing?

Are you taking birth control pills?

CONDITION OF ACCEPTANCE—ALL PATIENTS, PLEASE SIGN!!

I understand and agree that in accordance with Section 32.1-45.1 of the code of Virginia, that if a healthcare worker is exposed to my body fluids in a manner which may transmit HIV or Hepatitis B or C viruses, then I deem to have consented to testing for infection with HIV or Hepatitis B or C viruses, and to the release of such test results to the person exposed.

Signature

Click to Sign

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

Primary Dental Insurance

Insurance Co Name

Phone Number

Group #

Employer of Insured

Insured Party

Relation

Birth date of insured

SSN# or ID #

Secondary Dental Insurance

Insurance Co Name

Phone Number

Group #

Employer of Insured

Insured Party

Relation

Birth date of insured

SSN# or ID #

Permission To Leave Message

I give permission for Southside Endodontics to leave a message on this phone number

regarding (please check which apply):

appointment information

Yes No

co-pay/billing/account information

Yes No

medical information (e.g. biopsy results, etc.).

Yes No

Signature of patient or legal guardian

Click to Sign

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

Endodontic Consent

We want to inform our patients about the various procedures involved in endodontic therapy and have their consent before beginning treatment. Endodontic (root canal) treatment is performed to save a tooth which might otherwise need to be removed. The alternatives to endodontic therapy include no treatment or extraction. Risks involved in these alternative choices might include pain, infection, swelling, and tooth loss.

Endodontics or root canal therapy is cleaning, shaping, disinfecting, and filling the space inside the root of the tooth. A treated tooth usually functions normally and is a pulpless tooth, not a dead tooth. Treatment will require one or more visits depending on the condition of the tooth. Almost always, a local anesthetic will be needed to anesthetize (numb) your tooth. A number of dental radiographs (x-rays) will be made during the procedure. Please be advised of the following:

(1)   90% of routine cases are successful. Endodontics, as with any branch of medicine or dentistry, is not an exact science. Thus, no guarantee of treatment success can be given or implied. If the original treatment is not successful, the tooth may need to be retreated, a surgical procedure may be required, or the tooth may need to be removed.

(2)   Endodontic treatment started in other offices or re-treatment cases may have a different outcome than expected under optimal conditions.

(3)   Proper post-treatment restoration of the treated tooth is NECESSARY. Please contact your dentist as soon after completion of the treatment as possible to have the tooth restored. It is your dentist’s responsibility to restore the tooth. Most teeth will require a crown to prevent the tooth from breaking. Do not chew hard foods on the tooth until the final restoration is placed to protect the tooth from breaking or cracking. If the tooth splits, it may require extraction.

(4)   Possible unavoidable complications of endodontic treatment include but are not limited to:
Swelling, soreness, or muscle spasm
Fracture of the tooth or crown or bridge – if the tooth has a crown or bridge on it, we will have to drill through the restoration, which may result in the crown needing to be replaced. If the crown, bridge, or existing restoration must be replaced, it is the patient’s responsibility. It is not our responsibility to fabricate or pay for a new restoration for you. Separation or breakage of an endodontic instrument during treatment
Perforation of the root
Adverse reactions to anesthetics and medications administered and prescribed for treatment.

(5)   Some canals are blocked and may make root canal therapy impossible. These blockages can be caused by calcified canals, severely curved roots, root resorption, posts, fillings, or prior treatment.

(6)   Patients who are taking bisphosphonates and certain cancer medications have a small risk of developing osteonecrosis of the jaw from root canal therapy.

I hereby give my consent to the performance of endodontic treatment. I further give my consent for the administration of medications, anesthetics, and services deemed necessary to treat my endodontic problem, understanding the risks involved.

Signature of patient or legal guardian

Click to Sign

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

Payment Information

Each patient is financially responsible for his or her own account. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to this contract. As a courtesy, we will file all insurance claims for you.

Consultation, CBCT, local anesthesia, emergency treatment fee, and incomplete root canal treatment fees are due in full at the time of service, regardless of the type of insurance you may or may not have.

Fees for the root canal treatment are paid in the following manner.
• Patients without dental insurance: Payment is expected in full prior to service being rendered. Payments may be made with cash, check, or credit card.
• Patients with dental insurance: As a courtesy, we file all insurance claims. We will call your insurance company to get their estimated co-payment whenever possible. If we are unable to get an estimated co-payment from your insurance company, 50% of the root canal fee is to be paid at the beginning of treatment, and all insurance benefits are payable directly to Southside Endodontics. When all insurance benefits have been received, if any overpayment has been made, a refund will promptly be sent to you. If there is an additional balance due, we will send a statement to you. This balance will be fully due upon receipt. All unpaid balances are the patient’s responsibility.

If a root canal is started, but it is found that the tooth is not salvageable or root canal treatment cannot be completed, you will not be charged the full fee for the root canal treatment. Instead a reduced fee for services provided will be due.

I understand that if payment is not made when the account is due, there will be a finance charge of 1.5% per month (18% APR) and that my account may be turned over for collection. I will be responsible for any and all costs associated with the collection process, including but not limited to billing costs, collection fees, legal fees, and court costs.

Accounts will be turned over to collection agency if the balance is not paid in full within 60 days.

A $35.00 charge will be added to your account for all returned checks.

Please note, we are happy to help you understand and navigate your financial options and responsibilities—please don’t hesitate to ask!

I have read and understand the above financial policies.

Signature of patient or legal guardian

Click to Sign

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

truForm by PBHS

Southside Endodontics Patient Registration

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Chesterfield Office

DEMOGRAPHIC INFORMATION

Patient Information

In Case of Emergency

MEDICAL HISTORY

Have you had, or do you have any of the following (select "Yes" for all that apply):

MEDICATIONS & ALLERGIES

Medications & Allergies

This section is for women only

CONDITION OF ACCEPTANCE—ALL PATIENTS, PLEASE SIGN!!

Click to Sign

DENTAL INSURANCE

Primary Dental Insurance

Secondary Dental Insurance

Permission To Leave Message

Click to Sign

ENDODONTIC CONSENT

Endodontic Consent

Click to Sign

PAYMENT INFORMATION

Payment Information

Click to Sign

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Southside Endodontics Patient Registration

Main Header

Chesterfield Office

DEMOGRAPHIC INFORMATION

Patient Information

In Case of Emergency

MEDICAL HISTORY

Have you had, or do you have any of the following (select "Yes" for all that apply):

MEDICATIONS & ALLERGIES

Medications & Allergies

This section is for women only

CONDITION OF ACCEPTANCE—ALL PATIENTS, PLEASE SIGN!!

Click to Sign

DENTAL INSURANCE

Primary Dental Insurance

Secondary Dental Insurance

Permission To Leave Message

Click to Sign

ENDODONTIC CONSENT

Endodontic Consent

Click to Sign

PAYMENT INFORMATION

Payment Information

Click to Sign

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