This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable as a corollary to the planned endodontic therapy performed by Endodontic Associates and any assistant they may require. I agree to the use of local anesthesia Sedation, and/ or analgesia, depending upon the judgment of the endodonticist. Complicate ions of root canal therapy and anesthesia may include swelling, discomfort, infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent .

I also understand that only the root canal therapy is to be performed at this office. The permanent (outside) restorat -ion (filling, onlay, crown, etc.) will be done by my regular dentist.

I understand that medications for pain and sedateion may cause drowsiness which can be increased by the use of alcohol or other drugs. I will avoid operating any vehicle or hazardous devices while taking such medications. I further understand that certain medications may cause hives and intestinal problems and, if any of these reactions occur, I am to call the doctor immediately. I understand that it is my responsibility to report any changes in my medical history.

All reasonable collect ion and/ or legal costs required to collect fees due Endodontic Associates will be borne by the undersigned.



Past or Present Personal Medical History:



As specialists in the practice of endodontics (root canal therapy), we are committed to providing you with the highest level of care. Unlike other dental services, our treatment is usually completed in one or two visits. Therefore, payment for services rendered is expected when your treatment is completed. If we are able to complete root canal therapy in one visit, the fee for that service is due at that time. If you are required to return to our office for a second visit in order to complete your root canal, payment for the entire treatment may be divided equally between the visits.
If you provide our office with complete dental insurance information, we will gladly inquire on your behalf to verify what benefits may be applied to your fee for our services. If your insurance benefits entitle you to a reduced fee or provide for payment to our office (except for deductible or co-payment ), your portion of the balance is expected at the time of service.Our office will then submit your claim to your insurance company on your behalf for ribursement ., All co-payments are estimates until payment is received from the insurance company, any portion not covered will be the patient 's responsibility. We are not responsible for any misquotes by either our office or your insurance company. Please keep in mind that dental insurance is a contract between you and your insurance company. Therefore, if we do not receive payment from your insurance company within 30 days, the unpaid balance of your account becomes your responsibility. We will assess a monthly late fee of 1.5% on any outstanding accounts.

All reasonable collection and/ or legal fees required to collect fees due Endodontic Associates will be borne by the undersigned. We understand that occasional errors may occur in the processing of insurance claims. If you believe that an error regarding your account has occurred, please do not hesitate to contact our office. We will make every effort to rectify the problem in the timeliest manner possible. Your referral to our office indicates the confidence that your general dentist has in us for providing you with the best of care possible for this type of dental service. It is important to realize that your general dentist may participate with insurance companies other than those with whom we participate.

Your signature below indicates that you have read this statement and that you understand your responsibilities regarding payment prior to the initiation of any treatment by the doctors in our practice.


I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.

I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent .

Please use the space provided to list the people to whom you give written authorizationion for us to disclose your health and financial information to: