Mr. Mrs. Ms. Miss. Dr.

*First Name:

Middle Initial:

*Last Name:

*Street:

*City:

*Province:

*Postal Code:

Tel. Home:

Tel. Cell:

Tel. Work:

*E-mail:

*Date of Birth:

Family Dentist

Are you experiencing any discomfort at this time?

Yes No

Is the pain affected by?

Hot Cold Biting

Are you taking (taken) pain medication?

Yes No

General health:

Excellent Good Fair Poor

List all medications you are currently taking or provide a list to the receptionist:

Are you allergic to any of the following:

	Yes	No		Yes	No
Aspirin			Clindamycin
Codeine			Erythromycin
Ibuprofen			Latex
Local Anesthetics			Penicillin

Other medication allergies:

Indicate which of the following you presently have or have ever had:

	Yes	No		Yes	No
AIDS			Artificial Heart Valve
Anemia			Artificial Joints (Hip,Knee)
Angina pectoris			Asthma
Arthritis			Blood disorders
Blood thinners			Bronchitis
Cancer			Circulation problems
Congenital heart lesions			Cortisone/steroid
Diabetes			Emphysema
Epilepsy or seizures			Fainting or dizzy spells
Glandular problems			Glaucoma
Head/neck injuries			Heart disease or attack
Heart murmur			Heart Pacemaker
Heart rhythm disorder			Heart surgery
Hepatitis A			Hepatitis B
Hepatitis C			High/Low Blood Pressure
Hodgkin’s disease			Kidney disease
Liver disease			Lung disease
Malignant Hyperthermia			Nervous disorder
Mitral valve prolapse			Organ transplant/medical implant
Radiation treatment/chemotherapy			Rheumatic fever
Sinus trouble			Stomach/intestinal problems
Stroke			Thyroid disease
Tuberculosis			Ulcers
Osteoporosis

Other Condition(s)

Do you take Bisphosphanates (e.g. Fosamax) for Osteoporosis?

Yes No

Are you pregnant?

Yes No

Are you taking birth control pills?

Yes No

Are you nursing?

Yes No

Informed Consent: I understand Root Canal treatment is a procedure to retain a tooth that may otherwise require extraction. Although Root Canal treatment has a very high degree of success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth that has had Root Canal treatment may require retreatment, surgery, or even extraction.

I also understand that only treatment related to the Root Canal is to be performed at this office and any required restoration (filling, onlay, crown, etc.) will be done by my regular dentist.

Patient / Parent / Guardian Name:

hereby authorizes Endodontic Care to perform the service indicated, to administer local anesthetics, and to perform any added procedures which may be necessary to the welfare of the patient during the authorized services.

I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at or before completion of treatment, unless other specific arrangements are made with the receptionist.

I also authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically, I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I understand that this office follows the Federal Privacy Legislation (PIPEDA) in protecting my personal information. I consent to the sharing of personal information with my referring dentist and other dental/health care providers. I consent that this office will efficiently manage my account, including billing, debit and credit card payments, credit authorization, and for collection purposes

I understand that alternative treatments will be discussed and I will be given the opportunity to ask any questions before proceeding with treatment.