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The best patient-doctor relationships are maintained when there is a complete understanding of the treatment rendered and the fees charged. When endodontic treatment is complete, your tooth will require, for its protection, a permanent restoration or crown. That service is provided by your general dentist and is not included in our fee.

We appreciate your trust in us.

Patient Registration

Person Responsible for Account (if other than patient)

Dental Insurance Information

Primary Insurance:


Secondary Insurance:



PAYMENT IS DUE AS SERVICES ARE RENDERED. We are a fee for service practice. As a courtesy, we will gladly file your PRIMARY insurance for any procedure rendered and your insurance may reimburse you. A service charge of 1.5% per month (18% annually) will be automatically added to all the delinquent accounts past 20 days, from the date of service. All returned checks will incur a $35.00 accounting fee charge. If it becomes necessary to refer your account to a collection agency / attorney, then you will be responsible for any additional cost / fees incurred ion the process of collecting your outstanding balance.


Prior to your appointment day, we ask that you provide, to us, detailed insurance information. This will allow us to promptly and accurately file your claim, for you, on the day of your appointment. Our goal is to expedite and maximize your reimbursement. Also, please bring your incurance ID card to your appointment.

Are you currently taking or have you ever taken the following medications?

If you are taking birth control pills, antibiotics may inactivate birth control medication. Therefore, if you are taking antibiotics, additional birth control methods should be used until your next menses.

Permission For The Following Procedure: the undersigned, consent to the performing of whatever Endodontic Procedure (Examination, X-Ray, Root Canal, Apico Surgery, etc.) that may be decided upon to be necessary or advisable in the opinion of the Doctors. I also understand that I am to return to my dentist for permanent restoration of the treated teeth as soon as possible.


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