DF Example form

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

First Name

Middle Name

Last Name

Home Address

City

State

Zip Code

Home Phone

Cell Phone

SSN

Date of Birth

Person Responsible for Account (if other than patient)

First name

Last Name

Home Address

City

State

Zip Code

Home Phone

Cell Phone

Dental Insurance Information

Primary Insurance:

Employer

Insurance Company

Group Number

Subscriber Number

Date of Birth

mm/dd/yy

Employee Name (if other than patient)

Secondary Insurance:

Employer

Insurance Company

Group Number

Subscriber Number

Date of Birth

mm/dd/yy

Employee Name (if other than patient)

Primary Physician

Referring Dentist

OUR PAYMENT POLICY

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.

OUR INSURANCE POLICY

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?

Check all that apply

Please list any other medications you are currently taking:

Have you been a patient in a hospital in the past 2 years or under the care of a physician?

Yes No

Have you had an allergic reaction to any medications or local anesthetics?

Yes No

Please list:

Are you subject to prolonged bleeding?

Yes No

Select any of the following conditions which you have or have had:

Other:

Are you taking birth control medications?

Yes No

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.

Are you pregnant?

Yes No

Trimester?

Are you breastfeeding?

Yes No

Is there any other information we should know about your health or previous dental visit?

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.

Patient Name (Parent or Guardian if minor)

Today's Date

mm/dd/yy

Patient Signature (Parent or Guardian if patient is a minor)

Clear

Clear

Patient Registration

Person Responsible for Account (if other than patient)

Dental Insurance Information

Primary Insurance:

Secondary Insurance:

OUR PAYMENT POLICY

OUR INSURANCE POLICY

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

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