Consent for endodontic treatment

Patient’s Name: __________________________________________________
Date of Birth: ____________________________________________________
Social Security#: _________________________________________________
Street Address: ______________________________________________________________________________________________
City/Town: _______________________________________________State: ____________________Zip Code: __________________
Home Phone: __________________________ Cell Phone: _______________________ Email: ______________________________
Preferred Contact:
Primary Insurance Co. Name & Address: ________________________________________________________________________
Subscriber Name: ________________________________________ Subscriber Date of Birth: _____________________________

Subscriber ID #: ____________________________Group #: ______________________Employer: __________________________
Secondary Insurance Co. Name & Address: ______________________________________________________________________
Subscriber Name: ________________________________________ Subscriber Date of Birth: _____________________________
Subscriber ID #: ____________________________Group #: ______________________Employer:
Emergency Contact:
Primary Physician: ______________________________________ Phone: _____________________City:______________________

1. Within the last 3 years, have you been hospitalized or had surgery? □ Yes □ No
If yes, please give reasons and dates:_____________________________________________________________________________
2. Have you ever been instructed to take ANY medications ANY special precautions before dental appointments? □ Yes □ No
If yes, please explain:__________________________________________________________________________________________
3. Are you taking ANY drugs, medications, or treatments at this time? □ Yes □ No
(If you brought a complete list with you, give that to the receptionist instead.) Prescribed: __________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Over-the-counter (OTC) medications (such as Advil, allergy medication, sleeping aids, etc.): ___________________________________________________________________________________________________________ Vitamins, natural or herbal preparations and/or dietary supplements: ___________________________________________________________________________________________________________ Are you having or have you ever had radiation or chemotherapy treatments? □ Yes □ No If yes, for how long? __________________ Name of facility performing treatment: _____________________________
4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)? □ Yes □ No
5. Are you allergic to or have you ever had any reaction to any of the following?
___Penicillin (or related drugs)
___Aspirin/Ibuprofen (Advil, Motrin, Nuprin) ___Other(s) Specify

6. Do you have, or have you ever had, any of the following? (Please check Yes or No for each question.)

If yes, what joint or area: ______________________ When was the operation done: _________________ If yes, would you like to be treated for it? If yes, type & date___________________________ If yes, date_________________________________ WOMEN ONLY:
OTHER(s), conditions, diseases or medical problems ___ ___
____________________________________________________ ____________________________________________________ ____________________________________________________ Are you taking hormone replacement therapy? 8. Why do you seek dental treatment? __________________________________________________________________________
9. Do you consider the condition of your oral health:
Excellent ____ Good ____ Fair ____ Poor ____
10. When was your last dental visit? ________________________ What was done? ____________________________________
CONSENT – To the best of my knowledge, all of the preceding information is correct, and if there is ever any change in health or medications, this practice wil be
informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient’s health information released to
aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual
until further notice. I understand there are no guarantees or warranties in health or dental care. I understand that all x-rays taken in this office shal remain the
property of Lepine Dentistry, LLC. Should I desire a transfer of these records, I wil be responsible for a duplicating fee. I understand that all charges are my ultimate
responsibility. Non-sufficient funds fee is $50.00 and missed appointment fee is $75.00. I further understand that all balances remaining after insurance coverage (if
any) has fulfil ed its obligation are my responsibility. I understand that if I do not pay any amount which is owed you within 30 days after receipt of your statement of
services rendered, then I wil be in default of this agreement, and I wil pay 18% interest and the reasonable cost which you incur to collect the balance owed you,
including reasonable attorney’s fees equal to 35% of the balance, al owed by the ful extent permitted by law.
Signature__________________________________________________________________________ Date____________________
(Parent or guardian, if patient is a minor) Reviewed by: ___________________


Eial22_2 (12) final.pdf

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