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Patient Information Form

Form Instructions: (hide instructions)

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:
*Primary Phone:
Work Phone:
Other Phone:
Email Address:
Emergency Contact Name:
Emergency Phone #1:
Emergency Phone #2:
SSN:
*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:
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' or 'No' for any of the following which may apply to you now or in the past:
YesNo

 

YesNo

 

YesNo

 

YesNo

 

Congenital Heart Defects
Artificial Heart Valve
Heart Murmur
Heart Disease/Attack
Pain in Jaw Joints
Heart Surgery
Epilepsy or Seizures
Heart Pacemaker
Artificial Joint
High Blood Pressure
Rheumatic Fever
Tuberculosis
Mitral Valve Prolapse
Thyroid Condition
HIV Positive
Hepatitis:
A    B    C
Angina Pectoris
Diabetes
Bleeding Disorder
Drug Addiction
 
 
 
*Have you ever taken Bisphosphonates?
(i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec)
/
*Any other medical illness or concerns?
*Do you pre-medicate for a heart condition?
/
*Do you pre-medicate for an artificial joint?
/
If yes: * Date of surgery
For: Hip , Knee , other
*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 taking at present?
*Have you taken Aspirin or Ibuprofen in the last 72 hours?
/
If yes:
  
How many?
*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:

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

 

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