Please complete the Patient Registration Forms and press the Submit button to email them to our office. Thank you.
I have received a copy of this office’s Notice of Privacy Practices.
I, the undersigned, after consulting with the doctor, consent to the performing of whatever procedure may be decided upon to be necessary or advisable in teh opinion of the doctor.
I understand that root canal treatment is an attempt to save a tooth which otherwise requires extraction. Elective root canal therapy may be performed to provide space to anchor a final restoration and/or crown when insufficient tooth structure remains or to relieve excessive sensitivity to temperatures or as an adjunct to other specialty treatment. Although root canal therapy has high degree of success, it is still a biological procedure, so success cannot be guaranteed or warranted. Occasionally, a tooth that has had a root canal may require retreatment, surgery or even extraction.
It will be explained to me that there are certain inherent and potential risks in any treatment or procedure, including extraction and/or dental implant placement which may be alternative treatments instead of root canal therapy. I understand that the following may be potential risks of root canal treatment: numbness and/or a tingling sensation in the lip, tongue, chin, gums, cheeks and teeth, which is transient but on infrequent occasion may be permanent; treatment failure; complications resulting from the risks of dental instruments (broken instruments, perforation of the tooth, root or sinus); and antibiotics may inhibit the effectiveness of birth control pills.
Swelling or discomfort may be experienced after treatment by some patients. There is no way to predict this. Prescriptions for pain killers and/or antibiotics will be provided as needed.
I will have an opportunity to question the doctor concerning the nature of treatment, the inherent risks of the treatment and the alternatives to this treatment.
I also understand that only the root canal will be done in this office. The permanent (outside) restoration (filling and/or crown) needs to be done by my regular dentist within a maximum of an 8-week period.
I also acknowledge full responsibility for the payment of such services and agree to pay for them in full, at or before the completion of treatment, unless other specific arrangements are made with the office.
Thank you for choosing Midwest Endodontics for your endodontics needs. Our practice is dedicated to providing the best professional advice, care and endodontic treatment for our patients. Please understand that payment of your bill is part of your treatment. The following is an explanation of our Financial Policy for you to read and sign before seeing the doctor.
Payment in Full is due at the time services are rendered. We accept cash, check and most credit cards.
We also offer financing options available through an ACH Payment Plan or CareCredit. Please discuss this option with the receptionist if you are interested.
INFORMATION FOR PATIENTS WITH DENTAL BENEFIT INSURANCE:
Your insurance policy is a contract between you and your insurance carrier. It is a contract your employer negotiated with the insurance carrier. There will be a maximum dollar amount of coverage per year.
It is vitally important that you understand your coverage including any waiting periods or
No dental insurance is designed to pay 100% of treatment costs.
Therefore, at the time of treatment we will ask for a percentage payment based on what your insurance carrier will pay for endodontics services.
We offer an ACH Payment Plan or CareCredit as our financing options for patients who need it.
Our office is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance carrier’s arbitrary determination of usual and customary rates (UCR).
Once you are finished with the form, clicking print will allow you to bring in a printed copy to the office.