Medical History

Secondary Dental Insurance

The purpose of Endodontic treatment (root canal therapy) is to save your tooth rather than remove it. Although this treatment has a high rate of success, it cannot be guaranteed. A tooth that has had root canal treatment may require re-treatment, surgery or eventual extraction. Before any treatment is started, the reason(s) will be explained as well as alternative modes of therapy. Occasionally, an antibiotic may be indicated. This will be discussed in advance.

After treatment you must return to your general dentist to have your tooth restored with a permanent filling or crown. Fees incurred in another office are not included in our costs.

• 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 delinquent, 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 at a periodic rate of 1.5% per month, which is an ANNUAL PERCENTAGE RATE of 18%, applied to the last month’s balance. Also, 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 delinquent balance.