Patient History Form

Name

Date of Birth

Home Address

Cell Phone #

City and State

Apt #

Zip Code

Home Telephone

Business Telephone

Business

Address

Physician

Telephone

Dental Insurance Co. 1

Policy Number

Dental Insurance Co. 2

Policy Number

Medical Insurance Co.

Policy Number

Social Security Number

Parent's Social Security Number (if minor)

Root canal treatment is an attempt to retain a tooth that may otherwise require extraction. Although root canal therapy has a high degree of success, it cannot be guaranteed. Occasionally a tooth that has had root canal therapy may require treatment, surgery, or even extraction. I also understand that the root canal filling restores only the root portion of the tooth. The crown portion must be restored by an additional procedure, for an additional expense. I agree that if I do not pay for my dental treatment, I will be responsible for paying all collections costs and fees.

Patient History Form

Medical History

Condition of Tooth

Subjective Symptoms