Diplomate, American Board of Endodontics
Diplomate, American Academy of Pain Management

New Patient Information

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Please use the secure form below to submit your new patient information prior to your visit.

Patient Information:

Dental Insurance Information:

(Insurance will be handled on an individual basis depending upon the plan)

Your insurance company DOES NOT guarantee payment.  If after 45 days we do not receive payment from your insurance, you will become responsible for the balance.

Dental History:

Medical History:

Please answer all of the questions to the best of your ability.  Anesthetics and other medications that may be necessary in your dental treatment may interact with prescriptions, over the counter drugs, medications and illicit drugs.  These interactions may be serious.   You must disclose if you are a recovering alcoholic or drug user.

Are you allergic to or have you had reactions to:

Have you ever had or are you currently being treated for:

For Women Only:

By clicking submit I certify that I have answered the above questions to the best of my knowledge and my medical history is true and correct.


PLEASE READ:
At the first visit you will be advised as to the expected outcome, the number of appointments needed, what you may expect from treatment and alternative treatment options. Fees are quoted in advance of the treatment. The office policy is that payment in full must be completed by the last visit. Any problems regarding payment must be discussed with the receptionist prior to the completion of treatment. When treatment is completed your tooth will need final, permanent restoration or filling. The root canal fee does not include this service. Temporary filling will be placed in your tooth until you return to your dentist who will permanently restore the tooth.