Authorization and Consent for Endodontic Treatment
1. I hereby authorize Dr. Bruce R. Brown DDS to treat the condition described below:
oRoot Canal Therapy, tooth/teeth # _____________________
1. As in any treatment plan or procedure, there are certain inherent and potential risks.
I understand that the following may be inherent or potential risks for the treatment I will receive:
swelling; sensitivity; bleeding; pain; infection; numbness and/or tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth, which is transient but on infrequent occasions may be permanent; reaction to injections; changes in occlusion (biting); jaw muscle cramps and spasm; temporomandibular joint (TMJ) difficulty; loosening of teeth, crowns or bridges; referred pain to ear, neck or head; delayed healing; sinus perforations; treatment failure; complications resulting from the use of dental instruments (broken instruments-perforation of tooth, root or sinus), medications, anesthetics and injections; discoloration of the face; reactions to medications causing drowsiness and lack of coordination; and antibiotics may inhibit the effectiveness of birth control pills.
2. I have been given the opportunity to question the doctor concerning the nature of treatment, the inherent risks of treatment, and the alternatives to this treatment including no treatment at all.
3. It has been explained to me and I understand that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted.
4. This consent form does not encompass the entire discussion I had with the doctor regarding the proposed treatment.
5. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered and for the provider to release any information required to process insurance claims.
Patient’s Signature: _________________________________________________ Date: ____________
Office Financial Policy
1. Our policy requires payment in full for all services rendered at the time of visit, unless other
arrangements have been made. Payment plans are available and must be arranged at the time of the first
visit. If account is not paid within 90 days of the date of service and no financial arrangements have been
made, I will be responsible for legal fees, collection agency fees, interest charges and any other expense
incurred in collecting my account.
2. If we have agreed to accept your insurance as partial payment for services rendered, a statement will be issued for your portion when payment is received from the insurance company. I fully understand I am solely responsible for any balance not paid for by my insurance company. A finance charge of 1 ½ % per month will go into effect after 30 days of notification on your unpaid balance.
3. We must be informed of secondary insurance coverage upon registration. Otherwise we will be unable to accept assignment of the secondary insurance and you will be responsible for the balance remaining after the first company pays it’s portion of your fee.
4. I understand it is my responsibility to inform this office of any changes to the information I have provided.
I have read, and understand the above policies.
Patient’s Signature: __________________________________________________ Date: ____________