Family Dentist

Are you experiencing any discomfort at this time?

Is the pain affected by?

Are you taking (taken) pain medication?

General health:

Are you required to take any antibiotics (premedication) prior to dental treatment for any medical condition as recommended by a doctor?

List all medications you are currently taking or provide a list to the receptionist:

Other medication allergies:

Indicate which of the following you presently have or have ever had:

Are you pregnant?

Are you taking birth control pills?

Are you nursing?

Patient / Parent / Guardian Name:

hereby authorizes Endodontic Care to perform the service indicated, to administer local anesthetics, and to perform any added procedures which may be necessary to the welfare of the patient during the authorized services.

I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at or before completion of treatment, unless other specific arrangements are made with the receptionist.

I also authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically, I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I understand that this office follows the Federal Privacy Legislation (PIPEDA) in protecting my personal information. I consent to the sharing of personal information with my referring dentist and other dental/health care providers. I consent that this office will efficiently manage my account, including billing, debit and credit card payments, credit authorization, and for collection purposes.