RESPONSIBLE PARTY INFORMATION:

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1 Practice Limited To Endodontics 113A Tavern Road, Martinsburg, WV (304) Fax: (304) PATIENT HISTORY: M.I. Patient s Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender: Male or Female SSN: Birthdate: Nearest friend or relative to call in case of emergency: Phone: ( ) How were you referred to our office? Dentist Friend/Relative Name of person referring: RESPONSIBLE PARTY INFORMATION: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender: Male or Female SSN: Birthdate: Employer: Occupation: Employer s Spouse Information: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender Male or Female SSN: Birthdate: Employer: Occupation: Employer s PRIMARY DENTAL INSURANCE: Policy Holder s SSN: Company Policy #: Group# SECONDARY DENTAL INSURANCE: Policy Holder s SSN: Company Policy #: Group# I authorize the release of any information relating to any medical/dental insurance claim. I understand, I am responsible for all cost of treatment regardless of insurance coverage. Signature: Date:

2 PATIENT S MEDICAL HISTORY: M.I. Patient s Today s Date: Pharmacy: Do you need to be Premedicated prior to any dental work due to a heart condition or joint replacement? YES NO PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS WHICH APPLY TO YOU: Anemia/Blood Disorder Fainting/Nervous Mitral Valve Prolapse Arthritis Glaucoma Neck/Head Pain Asthma/Hay Fever Heart Trouble Pace Maker High Blood Pressure Heart Murmur Pregnant Low Blood Pressure Hepatitis/Liver Disease Rheumatic Fever Cancer Herpes Virus Stroke Diabetes HIV Positive/AIDS TB/Lung Disease Epilepsy/Seizures Joint Replacement TMJ/Clicking Joint Cardiovascular Disease (heart attack, angina, coronary insufficiency, coronary occlusion arteriosclerosis) Are you taking birth control pills? Yes Any other condition(s) not listed above?: Physician s Dentist s Are you presently taking any medication(s)? Yes If yes, please list the medication(s). Are you allergic or do you have a reaction to any medication(s)? Yes If yes, please list the medication(s). Are you allergic or do you have a reaction to latex? Yes The above information is true and complete to the best of my knowledge. Patient s Signature Date (Parent or Guardian if a minor)

3 Office Policy and Financial Agreement For the convenience of our patients, the following office policy and financial agreement has been established for your review. Credit Cards We accept Visa, MasterCard, Discover, and American Express. We offer these to allow you the most convenience in taking care of your account. Dental Insurance As a service to our patients, we will file your claim to your dental insurance. We work with your insurance company to provide the most accurate estimate of your co-pays. With insurance plans only paying a portion of treatment cost, we can only estimate what your insurance company will pay. Insured patients are responsible for, and should be prepared to pay all amounts not to be covered by the insurance estimate. If for any reason the claims go unpaid you will be responsible for all charges. Payment in full is required at the time of service for all non-insured patients. If your procedure is being completed in two steps, you may pay half at the first visit and the remaining balance at the second. Payment Plans We have made arrangements with the Care Credit Company to provide affordable payment plans. This allows you to complete your dental work without delay and make relatively small monthly payments. Applications are available and approval can be determined within ten minutes. For your convenience you can also apply online at Cancellations We reserve appointment time to properly serve our patients. If you are not able to keep your appointment please contact us immediately. This notice allows us the opportunity to serve other patients by placing them into the time slot. As a courtesy to all patients we ask that a twenty-four hour notice be given for a cancelled appointment. If we have not received sufficient notice, a charge may be applied to your account. The undersigned has read the above and agrees, whether he/she signs as a responsible party or as a patient, to pay Lori Gochenour, D.D.S., MS, PLLC, in full without regard to insurance coverage. I further agree to pay any collection fees, attorney fees, and court cost should these means of collection become required. Signature Date

4 ENDODONTIC CONSENT AND INFORMATION FORM Endodontic Root Canal Therapy, Endodontic Surgery, Anesthetics and Medications We would like our patients to be informed about the various procedures involved in endodontic therapy and have their consent before starting treatment. Endodontic (root canal) therapy is performed in order to save a tooth which otherwise might need to be removed. This is accomplished by conservative root canal therapy, or endodontic surgery. The following discusses possible risks that may occur from endodontic treatment, and other treatment choices. RISKS: Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections. These complications include (but are not limited to) swelling, sensitivity, bleeding, pain, infection, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks and teeth, which is transient but on infrequent occasions may be permanent; reactions to injections, changes in occlusion (biting), jaw muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth, referred pain to ear, neck and head, nausea, vomiting, allergic reactions, delayed healing, sinus perforations, and treatment failure. RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: The risks include the possibility of instruments broken within root canals, perforations (extra openings) of the crown or root of the tooth, damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals, and cracked teeth. During treatment, complications may be discovered which make treatment impossible, or which may require dental surgery. These complications may include: blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), splits or fracture of the teeth. MEDICATIONS: In most treatment cases, no medication is required other than over-the-counter pain mediations (ibuprofen preferably) to alleviate soreness, however, in some cases, an antibiotic regimen or prescribed pain medication may be necessary. Please be aware that prescribed medications may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any vehicle or hazardous device until totally recovered from their effects. OTHER TREATMENT CHOICES: These include no treatment, waiting for more definite development of symptoms, and tooth extraction. Risks involved in these choices might include pain, infection, swelling, loss of teeth, and infection to other areas. CONSENT: I, the undersigned, being the patient (parent or guardian of the minor named) consent to the performing of procedures decided upon to be necessary or advisable in the opinion of the doctor I also understand that upon completion or root canal therapy in this office, I shall return to my general family dentist for a permanent restoration of the tooth involved, such as a crown, cap, jacket, inlay, or filling. I understand that root canal treatment is an attempt to save a tooth, which may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally a tooth, which has had root canal therapy, may require retreatment, surgery, or even extraction. PATIENT (PRINT NAME) DATE PATIENT/PARENT SIGNATURE

5 CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION **PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY** Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health insurance information to carry out treatment, payment, activities and health care operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this consent. Our notice provides a description of our treatment, payment activities and health care operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice is available to you upon request. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices at any time by contacting: Contact Person: Dr. Lori L. Gochenour 113A Tavern Road Martinsburg, WV (304) Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I,, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Patient s Signature Date: If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name/Relationship: