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As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the cost incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for at the time services are performed. If I carry insurance, this office will prepare my insurance forms to assist in making a collection from insurance companies and will credit such collection to my account.
Please note that this dental office does not render services on the assumption that charges will be paid by an insurance company. A service charge of 1 1⁄2 per month (18% per annum - but in no event more than the maximum rate permissible under state law) will be charged on the unpaid principal balance on all accounts not paid within 30 days of treatment.
I understand that the fee estimate for this dental treatment can only be extended for six months from the date of the patient's examination. In consideration of the professional services rendered to me, or at my request, by the Doctor, I agree to pay the reasonable value of quoted services To this office at the time of services are rendered or within (5) days of billing if credit shall be extended, and that the reasonable value of quoted services shall be billed unless objected by me, in writing, within the time of payment thereof. Additionally, I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver for any future terms or conditions. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney's fees.
I authorize the Dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to me or my child during the period of such dental care to third-party payers and or health practitioners. I authorize and request my insurance company to pay directly to the dentist otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand that dental services furnished to me are charged directly to me and that I am personally responsible for the payment of all dental services.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
These questions are for your benefit and to assure treatment will take into consideration, your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with oral health care.
I acknowledge that the answers to the health questionnaire are true and correct and that I will inform the Endodontist of any changes in my health or medication. Consent for treatment: I hereby grant authority to the dentist (s) in charge of the patient whose name appears on this form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation, intravenous sedation, and to perform such operations as may be deemed necessary in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics, and/or drugs that will be administered.
Authorization must be signed by the patient, or by the nearest relative, in the case of a minor, or when a patient is physically or mentally incompetent.
OFFICE USE ONLY
I verbally reviewed the medical and dental information with the patient named herein.
Root canal treatment, also called Endodontic treatment is prescribed to relieve pain and discomfort when the nerve tissue (pulp) in the middle of the tooth and its root(s) can be reached by drilling through the biting surface of the tooth. Small delicate metal files are used to remove the pulp and the canals are cleaned, enlarged, and shaped to prevent further infection. Each empty canal is sterilized and filled with a rubber-like material to prevent bacteria from getting inside the tooth. Several radiographic images (x-rays) will be taken to check progress during the course of treatment. Depending on the pulp's condition, one to four visits can be expected. The opening in the tooth is closed with a temporary filling. An appointment for permanent restoration (such as a build-up or crown) will need to be made with your General Dentist.
If the infected pulp cannot be totally removed because of curved or blocked root canals, or your symptoms worsen and the tooth does not heal, an additional procedure called an Apicoectomy (root tip amputation) may be required to seal the root canal.
When root canal therapy is completed, the tooth tends to be brittle and the temporary seal will last only a short time. Failing to return as directed to seal and protect the tooth with a permanent restoration can lead to further decay, infection, gum disease or fracture requiring extraction even when the root canal treatment was successful.
Placement of medicaments will be determined during the course of treatment. Medicaments are used to ensure the success of treatments, minimize patient discomfort, and reduce the risk of relapse of infection. Medicament provisions are placed on an as-needed basis and will entail additional costs to the patient, as insurance will not cover the expense. In some instances, such placement of medicaments, like MTA, is used as alternative initial root canal therapy on teeth that have not fully developed. Such treatments will aid in subsiding symptoms and will allow for a long-term temporary treatment while the tooth matures further. This treatment is a provisionary treatment and does not replace the necessity for root canal therapy. The initiation of root canal therapy will be determined over the course of time by the treating Endodontist.
Patients presenting for treatment who have existing permanent restorations need to be advised that provisions to keep existing restorations intact are unlikely. In most cases, your current restoration will either be accessed through or cut off during the course of treatment to complete the necessary therapy. In this event, you will be advised to return to your general dentist for a new permanent restoration. This new course of restorative treatment will be at the sole expense of the patient.
Root canal treatment is meant to save your tooth for a longer period of time, in order to maintain your bite and jaw functions. Removal of your tooth is the most common alternative and may require replacement of the extracted tooth with a removable appliance, fixed bridge, or an artificial tooth called an implant.
There is a chance that root canal treatment will not resolve your problem even though the success rate is high. In such instances other procedures such as retreatment, Apicoectomy, even extraction may be necessary to resolve your problem. If these circumstances arise these procedures may result in additional charges to you.
Consequences of not performing treatment may lead to continued discomfort, risk of serious infection, abscesses in the gum and bone surrounding your teeth, and eventually, the loss of the tooth.
Every reasonable effort will be made to treat your condition properly, although it is not possible to guarantee the results of this treatment. By signing below you have read this document, understand the information about the proposed treatment, and have all your questions fully answered.
Notice to patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgment if you wish.
I acknowledge that I have received notice or a copy of this office's Notice of Privacy Practices.
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