Patient Information

Dental History

Medical History

Women Only

Informed Consent

I understand Root Canal treatment is a procedure to retain a tooth that may otherwise require extraction. Although Root Canal treatment has a very high degree of success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth that has had Root Canal treatment may require retreatment, surgery, or even extraction.

I also understand that only treatment related to the Root Canal is to be performed at this office and any required restoration (filling, onlay, crown, etc.) will be done by my regular dentist.

hereby authorizes Drs. Hepworth, Damas or Ionescu to perform the service indicated, to administer local anesthetics, and to perform any added procedures which may be necessary to the welfare of the patient during the authorized services.

I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at or before completion of treatment, unless other specific arrangements are made with the receptionist.

I also authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically, I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I understand that this office follows the Federal Privacy Legislation (PIPEDA) in protecting my personal information. I consent to the sharing of personal information with my referring dentist and other dental/health care providers. I consent that this office will efficiently manage my account, including billing, debit and credit card payments, credit authorization, and for collection purposes.

I understand that alternative treatments will be discussed and I will be given the opportunity to ask any questions before proceeding with treatment.