Updated Form

Patient of Record Updates
Name*

First NameLast Name
SSN
Required for MetLife and VA patients
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*
Name
Relation*
Phone Number*
Has your address change since the last time we saw you?*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Has your Primary Dentist change since we saw you last?*
Please list New Dentist name and number
Has your dental insurance change?*
Insurance Name & phone Number:
Are you the policy holder?:*
Policy holder's Name:*
Policy Holder's DOB:*

MonthDayYear
Insurance Member ID:*
Signature*

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Consent and Information Form

Regarding Health History, Endodontic (Root Canal) Therapy, Pre-Medication, Local Anesthetic and Medication.
It is the belief of this office that you should be informed about the treatment (therapy) and that you should give your consent before starting that treatment. The purpose of this form is to tell you of the risks that may occur in the endodontic (root canal) treatment, and other treatment choices.

Root canal therapy is done in order to retain a tooth (or teeth) which otherwise might need to be removed. Related dental surgery is done when needed.

Risks of treatment are two kinds: those risks involved in general procedures, and those specific to endodontic treatment.

RISKS OF DENTAL PROCEDURES IN GENERAL: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers) anesthetic and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth, thrombophlebitis spasms, (jaw) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues, referred pain to the ear, neck and head, nausea, vomiting, allergic reactions, itching, bruises, delayed healing, sinus complications, and further surgery. Medication and drugs may cause drowsiness and lack of awareness and coordination (which can be influenced by the use of alcohol or other drugs), thus it is advisable not to operate any vehicle or hazardous device, or work for twenty-four hours or until recovered from their effects.

RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: These risks include instruments broken within the root canals, perforations (extra openings) of the crown or root of the tooth, damage to bridges, existing fillings, crowns and porcelain veneers, loss of tooth structure in gaining access to canals, and cracked teeth. During treatment, complications may be discovered which make treatment impossible or which may require dental surgery. These complications may include: blocked canals due to fillings, prior treatment, natural calcification, broken instruments, curved roots, periodontal disease (gum disease/pyorrhea), splits or fractures of the teeth.

THE OTHER TREATMENT CHOICES INCLUDE: No treatment, waiting for more definite development of symptoms, having the tooth removed. Risks involved in these choices might include pain, swelling, loss of tooth, and infections to other areas. Treatment will be done in a manner to minimize or avoid the risks as success cannot be guaranteed.
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Financial Agreement
The total cost of your treatment is usually not covered by your dental insurance. As courtesy, our office will fill out and file a claim for you. We strive to have the latest insurance information to estimate the amount your insurance pays for the procedure(s); however, your insurance may determine payment differently than anticipated. Your insurance contract is between you, your employer, and the insurance company. We are not part of your contract. Regardless of what we may calculate your insurance company to pay, it is only an estimate. If there is a remaining balance left after you and your insurance have paid, a statement will be sent to you for the remaining balance. Pt's estimate and deductibles are due at time of service.
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Payment Options
For your convenience, we accept all major credit card payments as well as Care Credit, Cash/Check. Please note that a $30.00 service fee will be charged to your account on all returned checks.

All accounts are past due after 90 days and may be forwarded to the proper collection agency for processing unless prior arrangements have been made.
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HIPAA PRIVACY DISCLOSURE
THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Kevin R. Edwards,. L.L.C., and his team are dedicated to serving their patients with professionalism and care, being sure at all times to protect the privacy and security of all Protected Health Information.

During the course of serving your interest, it may be necessary to share information with other Health Cara Professionals or Business Associates. The following are examples of instances where information may be shared:

During treatment, we ay find it necessary to acquire a laboratory analysis.
For payment purposes, it may be necessary to forward radiographs and chart notes to your dental insurance company.
Final films and treatment information will be forward to your referring dentist.
For collection purposes information on accounts over ninety days without payment histroy or fianancial agreements may be forwarded to the proper agency for processing.
Dr. Edwards adn his team are committed to obeying all Federal, State and Local laws adn regulations regarding Privacy Practices. If uses or disclosures other than those listed above are needed, authorization from the individual in question will be requested. This writtin authorizaton may be revoked at any time by the individual, as provided for by law.
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Should be Empty:

Patient of Record Updates

Health History Update

Consent and Information Form

Financial Agreement

Payment Options

HIPAA PRIVACY DISCLOSURE