Patient Information



Patient Information

Date____________________ Home Phone_________________________ Cell Phone________________________

Name________________________________________________________ Soc. Sec #________________________

Last Name First Name Initial

Address_______________________________________________________________________________________

City________________________________________ State____________________ Zip______________________

Sex _ M _ F Age_____ Birthday_________________________ _ Single _ Married _ Widowed

Employer__________________________________________________ Occupation_________________________

Business Address________________________________________ Business Phone_________________________

In case of emergency who should be notified?______________________________ Phone____________________

Referring Doctor__________________________________________________ Tooth #______________________

Medical History

Primary Care Physician_____________________________________________ Phone_______________________

List all operations you have had in your lifetime _____________________________________________________

______________________________________________________________________________________________

(Women) Are you pregnant? _ Yes _ No Nursing? _ Yes _ No Taking BCP? _ Yes _ No

Name of OB/GYN Physician________________________________________ Phone________________________

Check ( ) if you have or have had any of the following:

__ Anemia __ Diabetes __ Kidney Disease

__Arthritis, Rheumatism __ Epilepsy __ Mitral Valve Prolapse

__ Artificial Heart Valve __ Fainting __ Pacemaker

__ Artificial Joints __ Glaucoma __ Radiation Therapy

__ Asthma __ Headaches or Migraines __ Respiratory Disease

__ Back Problems __ Heart Murmur __ Rheumatic Fever

__ Bleeding Disorder __ Heart Problems __ Shortness of Breath

__ Cancer __ Hemophilia __ Sleep Apnea

__ Chemical Dependency __ Hepatitis __ Stroke

__ Chemotherapy __ High Blood Pressure __ Thyroid Problems

__ Circulatory Problems __ HIV/AIDS __ Tuberculosis

__ Cortisone Treatment __ Jaw Pain or TMJ __ Ulcer

Medications currently taking (including over-the-counter)____________________________________________

______________________________________________________________________________________________

Do you have an allergic or adverse reaction to Latex? _ Yes _No

Have you had an allergic or adverse reaction to an anesthetic or drug? _Yes _No If yes, list the medications______________________________________________________________________________

Are you taking or have taken blood thinners? (Coumadin, Platelet Inhibitors, or Aspirin Therapy) _Yes _No

If yes, reason why_______________________________________________________________________________

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his staff at Root Canal Specialists responsible for any errors or omissions that I may have made in the completion of this form.

Date____________________ Signature_____________________________________________________________________________________

Financial Policy

For

Root Canal Specialists

I understand that my financial obligation for diagnostic services and treatment is between Root Canal Specialists and me, not between Root Canal Specialists and my insurance company.

Those with dental Insurance: Root Canal Specialists currently participate with Anthem Blue Cross & Blue Shield, Cigna, Decare, Dentemax, Delta Dental, Delta Care and Care Credit. Root Canal Specialists will estimate the portion your insurance is going to pay. This is only an estimate since the amount covered varies from company to company. Usually 25-50% of the cost of the procedure is required at the time of service, depending upon the insurance company. As a courtesy, Root Canal Specialists will file the claim with your insurance company. Please keep in mind, however, insurance companies routinely indicate that coverage verification does not guarantee payment.

The amount that each insurance company will cover depends upon:

Insurance Company, Allowable procedures, Remaining benefits, etc.

If you require nitrous oxide sedation, this is not a covered item by insurance companies.

The cost of nitrous is $100.00, which the patient is responsible for at time of service.

If the doctor feels that a CBCT (3D) scan is necessary for correct diagnosis and treatment, a $100 charge will be added to your treatment cost. A CBCT scan is not covered by insurance, and is the responsibility of the patient at time of service

If root canal therapy is initiated but the tooth is found to be not salvageable, you will not be charged for the full treatment. An inoperable fee of $375.00 will be charged for services provided which may or may not be covered by your insurance.

Social Security Numbers are required to be disclosed to Root Canal Specialists in order to file insurance claims. Patients can decline to disclose the information requested; however, the patient will be responsible for account balance the day of service.

Those without dental insurance: Payment is due in full at the time of service.

No in house payment plans are offered at Root Canal Specialists. Root Canal Specialists is a provider of Care Credit. To apply for CareCredit, call 800-859-9975 or apply online at

If your insurance pays more than the amount we estimated, a refund check will be issued from this office.

If your insurance pays less than the estimated amount, you will receive a statement from this office. Payment is due in full upon receipt of the statement.

Any unpaid insurance balances after 45 days become my immediate obligation to pay and not that of my insurance carrier. After 90 days, any unpaid balance automatically rolls over and is referred to a collection agency, and a collection fee of 18% will be applied to the unpaid balance.

A $25.00 charge will be added to your account for all RETURNED CHECKS.

I also understand that I will be responsible for any additional fees incurred as a result of any collection efforts by Root Canal Specialists.

Signature____________________________________ Date: ___________________

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