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Confidential Patient Information

Dental Insurance Information

Medical History

For Women Only


By entering your name below, you certify that all the information provided is accurate and complete to the best of your knowledge and belief:

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Thank you for choosing Moreno Valley Endodontics. Should you have questions concerning your treatment, treatment sequence, or fees for services, please ask for clarification before treatment is begun.

Our financial policy is as follows:

  • We accept cash, checks, debit cards, and credit cards.
  • Payment is due at the time of service.
  • Payment plans for certain procedures are available through Care Credit with payment options available up to 24 months at fixed rates.
  • Insurance is a contract between the patient and/or employer and the insurance company. It is not a contract between our office and your insurance company. We will be happy to assist you by filing your insurance claim and answering the details that the insurance company may require. We cannot be responsible for payment by the insurance company. The responsibility for payment belongs to the patient.
  • We will provide estimated balances between the cost of service and co-payment of your insurance. Predetermination of benefits may be advisable if there is a question concerning coverage.
  • All remaining balances on your account should be resolved within 10 days of the final insurance payment or financial arrangement.

We reserve the right to accept or deny certain insurance plans at our discretion. If we accept your insurance plan, your copayment is due at the time of service.

I agree to be responsible for all dental charges for dental services and material not paid by my dental plan, unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with all dental claims.

I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the dentist or dental entity.

Should your insurance plan be denied, full payment is expected at the time of service unless prior arrangements have been made though our office manager.

Please remember that you are responsible for timely payment of your account. "In the event of nonpayment I agree to be responsible for any legal or collection fees. The collection fee is a percentage of the total balance turned over to an outside agency. I agree to be responsible for these fees."

I understand the above policy and agree to the terms herein.


Type your full name below to acknowledge and accept our Dental Services Financial Agreement as stated above.

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I understand I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996(HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g. my insurance company);
  • The day-to-day healthcare operations of your practice.
  • Appointment reminder through telephone, text or email.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions.

However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.


By entering your name below you are acknowledging and accepting this Patient HIPAA Consent Form as stated above.

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ACBCT scan, also known as a Cone Beam Computed Tomography, is an x-ray technique that produces 3-D images of your teeth that allows visualization or internal bony structures in cross-section rather than a s overlapping images typically produced ov conventional x-ray exams. CBCT scans are primarily used to visualize bony structures, such as teeth and your jaws, not soft tissue such as your tongue or lips. A dental CBCT will typically capture 3-4 teeth ni a region.

Advantages of a CBCT scan over conventional x-rays: A conventional x-ray of your mouth limits your dentist to a two-dimensional or 2D visualization. Diagnosis and treatment planning can require a more complete understanding of complex three-dimensional or 3D anatomy. Advantages of CBCT scans include:

A) Enhanced patient safety, more predictable outcomes, less discomfort, and faster treatments.

B) Greater chance for diagnosing conditions such as vertical root fractures and endodontic pathology that can be missed on conventional x-rays.

C) Greater chance of providing images and information which may result inthe patient avoiding unnecessary, and sometimes invasive, dental treatment.

Radiation: CBCT scans, like conventional x-rays, expose you to radiation. The amount of radiation you will be exposed to is the the equivalent to what you would receive from several days of normal background environmental radiation. The dose of radiation used is caretully controlled to ensure the smallest possible amount is used that will still give a useful result. However. all radiation is linked with a slightly higher risk of developing cancer (3 in 1,000,000). But the advantages of a CBCT scan outweigh this disadvantage.

Pregnancy: Woman who are pregnant should not undergo a CBCT scan due to the potential danger to fetus. Please tell the dentist if you are pregnant or are planning to become pregnant.

Diagnosis of non-dental conditions: While part of your anatomy beyond your month and jaw may be evident from the scan, your dentist may not be qualified to diagnose conditions that may be present in those areas. If any abnormalities, asymmetries, or common pathologic conditions are noted upon the CBCT scan, ti may become necessary to send the scan to an Oral and Maxillofacial Radiologist for further diagnosis. CBCT scans cannot be relied upon to show soft tissue lesions, unless they have caused changes in the hard tissues (teeth or bone). Also, CBCT images may contain artifacts that can make interpretation difficult. By signing this form, you are acknowledging that your dentist may not be qualified to diagnose al conditions present, and that his/her liability only extends to the limits of the dental purpose of the scan and its interpretation for that purpose.



Enter your full name below to acknowledge and accept our CBCT Consent Form as stated above:

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For Office Use Only:

Doctor Signature: x ________________________________________ Date ________ /________ /________

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