PLEASE PRINT Date ________________________ SINGLE MARRIED

Name______________________________________________________Sex: M F WIDOWED DIVORCED

Address_______________________________________________________________ SEPARATED

City ______________________________________________________State ___________________ Zip Code ______________

Home Phone ___________________________ Mobile Phone ___________________________ Birthdate _________________

Email ____________________________ Bus. Phone __________________________Soc. Sec. # ________________________

Employed By _______________________________________________________ Medical Doctor's Name

Occupation _________________________________________________________ ___________________________________

Referred By _________________________________________________________ Dentist's Name

Name of Parent / Spouse _____________________________________________ ___________________________________

Person Responsible for Payment If other than Above ______________________________________

Relationship to Patient ( ) Spouse ( ) Parent or Guardian Does This Person Reside in the Same Household? Yes No

Address _________________________________________________________________________________________________

City _____________________________________________________State ____________ Zip Code ______________________

SS # __________________________ Home Phone ______ ___________________ Work Phone______ ________________

Employer’s Name __________________________________________________ Occupation ___________________________

Emergency Contact _________________________________________ Phone Number _______________________________

ENDODONTICS LIMITED, P.C.REGISTRATION FORM

HEALTH QUESTIONS

Is your general health good? ...................................................................................................................... Yes No

Are you under a physician’s care now? ..................................................................................................... Yes No

Heart MurmurHeart TroubleMitral Valve ProlapseHigh Blood PressurePacemaker for HeartPhen Fen DietArtificial Joints

Overactive ThyroidUnderactive ThyroidHerpesAIDS/HIVUlcerDiabetesNervous Disorder

AsthmaBleeding DisordersSeizuresOsteoporosisTuberculosisCancer

Rheumatic FeverHepatitisCurrently PregnantArthritisAutoimmune DiseaseLatex Allergy

Yes No Yes No Yes No Yes No

Have you ever had an allergy or unusual reaction to any drug, general or local anesthetic? (If yes, list) Yes No

Is there any other information about your health that should be known? ................................................ Yes No

List all medications that you presently take and why:

Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________

Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________

Drug ___________________ Condition ___________________ Drug ___________________ Condition ___________________

I have been given a copy of “Important Facts About Root Canal Therapy” and have been advised to read it and ask any questions regarding the contents that I do not understand.

Signed ______________________________________________________ Dr.________________

If you have Dental Insurance Turn to Back of this Page to Continue

If you have dental insurance fill out the following:

What amount do you think is covered by your insurance towards root canal therapy?

Don’t Know 100% 80% 50% 25% Other

Please check one of the following:

I plan to pay the doctor directly and I will be reimbursed by my insurance company.

If possible I would have the insurance company pay the doctor directly and I understand that I am responsible for any amount not covered by insurance.

My Dental Insurance:

( ) Is provided by my employer:

Name of insurance company or Union _________________________________________

Number on Insurance Card __________________________________________________

( ) Is provided by my spouse’s/parent’s employer:

Spouse/Parent Name ___________________________________________________________________________

Spouse/Parent works for ____________________________ Ins. Co. _____________________________________

Spouse/Parent SS# _______________________________ Spouse/Parent B’day________________Sex: M F

( ) I purchase my own dental insurance:

Insurance Co. _______________________________________ Address __________________________________

NOTE:

Due to the constantly changing insurance rules and regulations, benefits and deductibles, we areonly able to approximate your insurance balance. If your insurance pays more than expected youwill be credited the difference. If your insurance company pays less than expected you will be billedthe difference. Final responsibility for payment rests with the person responsible for your account.

I authorize the doctors to release any information necessary to process my claim.

Date ____________ Signature ________________________________ Relationship to Patient _____________

If patient is covered by more than one insurance fill out.

Secondary Dental Insurance

Employee’s Name _______________________________________________________ Birthdate _______________Sex: M F

SS # or Subscriber Number Shown on Card _________________________________________________________________

Employer’s Name _________________________________________________________________________________________

Insurance Company ____________________________Address ___________________________________________________

Relationship to Patient: ( ) Self ( ) Spouse ( ) Parent/Guardian Group # ______________________________

FORM 100680 ENDODONTICS LIMITED, P.C. ITEM 40684