I hereby give my consent to Dr. Zoufan and his assistants to perform an initial examination prior to any definitive treatment. This consent is for evaluation only and no invasive treatment will be performed prior to discussion of proposed treatment with the doctor and trained staff.
This initial evaluation consists of, but is not limited to: examination of diagnostic radiographs and dental CT scan, pulp vitality testing, localized periodontal examination, and definitive treatment planning. I understand that in some instances, a local anesthetic (numbing) may be needed for diagnostic purposes.
I understand that diagnostic radiographs may be needed at the doctor's discretion. I also understand that the doctor may require consultation with other dental and medical professionals prior to the initiation of any treatment. I authorize Zoufan Endodontics to obtain any necessary medical history or clearance for treatment from my physician(s) and to send any necessary dental records either to those actively participating in my care or to me personally.
I understand there is a fee for initial consultation. As a courtesy, Zoufan Endodontics will submit an insurance claim on my behalf; however, I am ultimately responsible for the balance.