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Online Patient Information Form

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Patient Information
Not Completed

Medical History
Not Completed

Dental Insurance
Not Completed

Patient Care Policy
Not Completed

Section One: Patient Information

Date:
*Last Name:
*First Name:
Middle Initial:
Name Preference:
*Address:
Apt Number:
*City:
*State:
*Zip:
*Home Phone:
Work Phone:
Cell Phone:
Email Address:
Social Security Number:
*Date of Birth: (Month, Day, Year
,
*Sex: / 
Spouse:
Employer:
Employer Address:
*General Dentist:
Physician:
*Referred By:
How did you hear about us? Dentist, Friend, Internet, Telephone Book, Other:
Emergency Contact Name:
Work #:
Home #:
Preferred Pharmacy:
Cross streets:
Patient is less than 18 years old. Please complete the following:
*Responsible Party:
SSN:
*Street Address:
Apt#
*City:
State
*ZIP:
*Primary Phone:
Work Phone
*Relationship to Patient

Section Two: Medical History

*Please check 'Yes', 'No', or 'UK' (unknown) for any of the following which may apply to you now or in the past:
Yes  No UK

 

Yes  No UK

 

Yes  No UK

 

Yes  No UK

 

Artificial Heart Valve
Tuberculosis
High Blood Pressure
Diabetes
Rheumatic Fever
Hepatitis:
A    B    C
Heart Murmur
Thyroid Condition
Mitral Valve Prolapse
HIV Positive
Heart Surgery
Angina Pectoris
Drug Addiction
Pain in Jaw Joints
Bleeding Disorder
Artificial Joint
Congenital Heart Defects
Heart Attack
Stroke
Heart Pacemaker
Epilepsy
Seizures
 
 
 
*Any other medical illness or concerns?
*Have you ever had an unusual reaction to latex, an anesthetic, or drug such as Penicillin, Erythromycin, Novacaine, Codeine, Aspirin, Sulfa, or any other medications?
If yes, please explain:
What medications are you currently taking?
*Have you ever taken Bisphosphonates?
(i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec)
If yes, please list:
*Are you currently taking a blood thinner?
If yes, please list:
*Are you able to take Ibuprofen?
*Are you required to take antibiotic premedication prior to dental appointments?
If yes, list reason (heart condition, joint replacement) and name of antibiotic:
If joint replacement, date of surgery
*Women - Are you pregnant?
/
If yes, what month?

Section Three: Dental Insurance

Please verify my insurance.(*Please fill out all insurance information)
Contact me regarding my insurance.
I do not have insurance.

Primary Dental Insurance

*Name of Insured Person (Employee):
*Relationship to Patient:
*Member ID:
*Date of Birth: Month, day, Year
,
*Employer/Retired From:
Length of Employment:
*Insurance Company:
Group #:
Insurance Phone:
Address:
City:
State:
Zip:

Section Four: Patient Care Policy

Endodontic Treatment

Endodontic Treatment (root canal therapy) is to save your tooth rather than remove it.  Although treatment has a high degree of success, it cannot be guaranteed.  A tooth that has had a root canal treatment may require re-treatment, surgery or even extraction.

Before any treatment is started, the reason(s) will be explained: including alternative modes of therapy. Occasionally, pre-medication may be indicated. This will be discussed in advance.

After treatment you must return to your general dentist to have your tooth protected with a permanent filling or crown; this is not included in our cost.

  • I consent to necessary treatment and authorize the release of any information needed for continued care.
  • I authorize the release of information to my insurance company & payment of benefits directly to provider. Any balance not paid by my insurance will be due within two weeks of the statement date.
  • I am financially responsible for fees incurred at the time of service. In the event my account becomes deliquent, I understand a LATE FEE up to $10 and/or a SIMPLE INTEREST CHARGE will be added to the account. The INTEREST CHARGE will be a periodic rate of 1.5% per month, which is an ANNUAL PERCENTAGE RATE of 18%, applied to the last month's balance. In addition, an additional 30% of the principal balance due will be added to help cover the cost of collection. I understand that I am responsible for attorney's fees, interest and court costs should it become necessary that legal action be taken, and that a credit report will be obtained for the sole purpose of collecting a deliquent balance.

Patient Responsibility

I have read and understand Southern Arizona Endodontics' policies and procedures as presented above and I affirm that I am responsible for fees incurred at the time of service.

*Name:

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Date:



Congratulations!

All sections of the form are now complete.

If You wish to review any form section (optional) please click on the "Reveiw Section" button in the appropriate Section Status block at the top of the form.

Once you have finished any review of the form, you may press the "SEND" button to securely send the form to Southern Arizona Endodontics.

  1. After you press the "Send" button, here is what will happen:
    1. The form will re-display with a note at the top of the form that specifically tells you the form has been successfully sent or has not been successfully sent to Southern Arizona Endodontics.
    2. If your attempts to send your online form to SAE are unsuccessful (no "successfully sent" message at the top of your online form after pressing the "send" button), please call SAE at (520) 322-0800.
  2. Now, when you are ready, press the "Send" button to transmit your online form to Southern Arizona Endodontics.

Thank you for taking the time to complete your registration form online. Southern Arizona Endodontics staff will review your completed form with you when you arrive for your appointment.



Three Convenient Locations

1011 N. Craycroft Rd. Suite 107
     Tucson, AZ 85711
7493 N. Oracle Rd, Suite 217
     Tucson, AZ 85704
512 E. Whitehouse Canyon Rd, Suite 120
     Green Valley, AZ 85614

 
Call us at 520-322-0800

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Craycroft Road
Oracle Road
Green Valley

 

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Call 520-322-0800

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Southern Arizona Endodontics Since 1984