SAE Logo Welcome to Our Office!
 
 


This form has two major sections. They are:

Section One: Patient Information. Here you provide us with personal information that allows us to better understand your needs and therefore serve you best.

Section Two: Acknowledgement of Receipt of Notice of Privacy Practices. This is a form we must keep on file that documents we have your authorization to email specific health information to general dentist or dental specialist. This form is required by applicable federal and state laws to maintain the privacy of your health information.

Once you have completed both sections, please press the submit button at the bottom of form to sumbit the form data to us.

Thank you for the opportunity to serve you. We greatfully appreciate your business.

Section One: Patient Information
Date:
*Indicates Required Information.
Please Choose:         
Last Name* First Name* MI Name Preference
Street Address* City* State* Zip*
Home Phone* Work Phone Cell Phone Email Address
Social Security # Date of Birth Sex* Spouse
,  / 
Employer Employer Address
General Dentist* Physician Referred By:*
School:
In Case of Emergency Contact:*
Name* Home Phone:* Work Phone:

Medical History

Please check Y for “yes” or N for “no” for any of the following which may apply to you now or in the past:*
Y N   Y N   Y N  
Congenital Heart Lesions Artificial Heart Valve Heart Murmur
Heart Disease or Attack Pain in Jaw Joints Heart Surgery
Epilepsy or Seizures Heart Pacemaker Artificial Joint
High Blood Pressure Rheumatic Fever Tuberculosis
Mitral Valve Prolapse Thyroid Disease HIV Positive
Hepatitis A, B, or C Angina Pectoris Diabetes
Bleeding Disorder Drug Addiction      
Have you ever taken Bisphosphonates?* /
(i.e. Fosamax, Aredia, Zometa, Actonel, Boniva, Skelid, Didronel, Bonefos Ostec)
Any other diseases or problems?
Have you ever had an unusual reaction to latex, an anesthetic, or drug such as Penicillin, Erythromycin, Novacaine, Codeine, Aspirin, Sulfa, or any other medications?*  /
If yes, please explain:
What medications are you taking at present?
Have you taken Aspirin or Ibuprofen in the last 72 hours?* /
If yes:    How many?
Women - Are you pregnant? / If yes, what month?
THE PURPOSE of endodontic treatment or root canal treatment is to save the tooth rather than remove it.  Although treatment has a high degree of success, it cannot be guaranteed.  Occasionally, a tooth that has had a root canal treatment may require re-treatment, surgery or even extraction.

Treatment is usually a non-surgical procedure, but in some cases, a surgical approach is necessary.  Before any treatment is begun the reason(s) will be explained, including alternative modes of therapy.  Occasionally, pre-medication may be indicated.  This will be discussed in advance.
 
PLEASE NOTE: The fee will not include a permanent filling or crown on the tooth. You must return to your general dentist to have that treatment completed.
 
I consent to necessary treatment and authorize the release of any information needed for further treatment.*
Signature of Patient (Custodial Parent/Guardian of Minor)* Date
Please verify my insurance.(*Please fill out all insurance information)
Contact me regarding my insurance.
I do not have insurance.

Primary Dental Insurance

Name of Insured Person (Employee): Relationship to Patient:
Member ID (must be 9 digits): Date of Birth (m/dd/yyyy): ,
Employer/Retired From: Length of Employment:
Insurance Company: Group #: Insurance Phone:
Address: City: State: Zip:

Secondary Dental Insurance

Name of Insured Person (Employee): Relationship to Patient:
Member ID (must be 9 digits:) Date of Birth (m/dd/yyyy): ,
Employer/Retired From: Length of Employment:
Insurance Company: Group #: Insurance Phone:
Address: City: State: Zip:
I hereby authorize the provider to file my insurance and benefits to be paid directly to the provider.
I also understand that when my particular insurance is filed:
  1. I authorize the release of any information related to my claim to my insurance company.

  2. I am ultimately responsible for the balance on my account for any professional services rendered regardless of the amount my insurance pays toward my account. We ask that patients with insurance pay estimated portion of the cost of treatment; at the time service is received.

  3. Any balance not paid by my insurance will be due within two weeks of the statement date, a LATE FEE and/or SIMPLE INTEREST CHARGE may be added to the account. The INTEREST CHARGE will be a periodic rate of 1.5% per month, which is an ANNUAL PERCENTAGE RATE of 18% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection on this account.

If patient is under the age of 18 years old, please complete the following:
Responsible Party: SSN:
Street Address City State Zip
Home Phone Work Phone Relationship to Patient
I understand that I am ultimately responsible for fees incurred at the time of service.*
Signature of Patient (Custodial Parent/Guardian of Minor)* Date

Section Two: Acknowledgement of Receipt of Notice of Privacy Practices

AUTHORIZATION TO E-MAIL HEALTH INFORMATION TO GENERAL DENTIST OR DENTAL SPECIALIST

Signature Optional 

 
1. Security Guidelines (HIPAA)

A.     I understand that under the new HIPAA security regulations, that any information regarding my visit to Southern Arizona Endodontics cannot be sent electronically to my General Dentist or Dental Specialist without my written permission, and that the HIPAA Security guidelines are to safeguard my electronic health information. 

B.     The information that will be sent electronically includes the following:

  1. Patient Name
  2. Tooth #
  3. An electronic image of your tooth
No other personal information will be sent electronically (i.e. social security number, or date of birth).

It is important for you to know that SAE understands the importance of keeping personal information protected, and will do everything possible to ensure that protection. 

2. STATEMENT OF UNDERSTANDING
I have received a copy of this office’s Notice of Privacy Practices. I give my permission for my name, tooth #, and electronic image of my tooth to be sent via e-mail to my general dentist, or other dental specialist.

Signed: Date:  

Witness:______________________________________________ Date: _________ 
                                                  (SAE)

For Office Use Only 

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: 

  1. Please press the Submit button once you have reviewed your entries.
  2. Press the Clear Form button to clear all form entries and start anew.