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This form is completed in four sections: Patient Information, Medical History, Dental Insurance, and Patient Care Policy.
As you complete each section the form will automatically check your entries and highlight (in red) entries that are incomplete.Once a section is complete, the form will automatically display the next section for you to complete.A progress status of form completion is also displayed (at the top of the form) as you complete each form section.
After completing all four sections, you will be able to review/edit any section before sending the form data to Southern Arizona Endodontics.
1. It is best to use the tab key to move between form entries.
2. Items marked with a red asterisk(*) Indicates fields that are Required entries. These fields must contain entries.
Thank you for the opportunity to serve you. We gratefully appreciate your business.
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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 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.
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Please verify that you are a human.
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.
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.