Patient Registration Form

Name:

First, Middle Initial, Last

Date *

MM/DD/YY

Billing Address *

Billing Address

Street Address

Street Address cont'd

City

State/Province

Zip/Postal

Country

Date of Birth

MM-DD-YY

Social Security Number

000-00-0000

Driver's License #

Primary Phone *

000-000-0000

Other

000-000-0000

Emergency Contact

000-000-0000

Nickname

Employer

Gender *

Male

Female

Status

Single

Married

Child

Party Responsible for Account *

Name of Party

Relationship to Patient

Phone

000-000-0000

Referring Dentist

Name of Dentist

Email

I authorize the following individuals to have complete access to my account:

Health History

Do you currently have or have you ever had any heart problems?

Yes

No

Are you currently taking or have ever taken bisphosphonate drugs?

Yes

No

Have you ever had artificial prosthesis, hip replacement, etc.?

Yes

No

Do you currently take premedication for dental treatment?

Yes

No

Have you ever been hospitalized for a serious illness?

Yes

No

Women: Are you pregnant?

Yes

No

Due Date:

MM-DD-YY

Please list any medications, vitamins, supplements that you are currently taking.

Please read and sign:

I, the undersigned, being the patient, parent, or guardian of the above minor patient consent to the performing of any procedure that they may be deemed necessary by the doctor. I authorize and request the administration of such drugs and/or anesthetics as may be deemed advisable by the doctor. I also understand that upon completion of the root canal therapy, I will be referred to my dentist for permanent restoration, such as; composite restoration, onlay, or crown. I certify the attached health history to be correct.

Signature Patient *

Clear

Signature is required

Signature Doctor

Date

MM-DD-YY

Insurance Information

Primary Insurance Company

Subscriber Name

Subscriber Date of Birth

MM-DD-YY

Subscriber SSN/ID#

000-00-0000

Employer

Secondary Insurance Company

Subscriber Name

Subscriber Date of Birth

MM-DD-YY

Subscriber SSN/ID#

000-00-0000

Employer

Fees

Services

Anteriors Root Canal Therapy - $1395.00
Premolars Root Canal Therapy - $1610.00
Molars Root Canal Therapy - $1960.00
Limited Evaluation - $260.00
Anteriors Root Canal Therapy Retreatment - $1520.00
Premolars Root Canal Therapy Retreatment - $1790.00
Molar Root Canal Therapy Retreatment - $2050.00

Billing Policy

We are committed to providing you with the best possible care available. Our office is not contracted as a provider for ANY insurance company due to the limitations they attach to treatment, regardless of the diagnosis. Our commitment is to you, our patient, not to any insurance company.
WE BILL YOUR INSURANCE AS A COURTESY. A portion of the total treatment with any deductible is due at time of service. If your insurance does not pay for any reason within 60 days your balance is your responsibility.
It is also up to you to check with your insurance on any outstanding dental claims. We will provide you with any information you might need.

Payment Options

Select all that apply

Payment Policy

IF YOU WOULD LIKE ALASKA ENDODONTIC SPECIALISTS TO FILE YOUR INSURANCE YOU MUST PROVIDE THE CREDIT CARD INFORMATION BELOW.
Otherwise, payment in full is expected
I authorize Alaska Endodontic Specialists, LLC to charge the outstanding balance of my account to the card listed below after my insurance payment is received or when my account reaches 60 days (whichever is earlier). Please tell the receptionist if you would like us to call prior to running your card. THIS INFORMATION WILL BE DESTROYED ONCE PAYMENT IS RECEIVED IN FULL.

Cardholder Name

As it appears on the card.

Card Number

xxxx xxxx xxxx xxxx

CVV2#

Located on back of card next to signature.

Expiration Date

MM/YY

AUTHORIZATION AND RELEASE OF INFORMATION

I authorize Alaska Endodontic Specialists, LLC to release information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or other health practitioners. Additionally, I authorize photocopies of this form to be as valid as the original.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. If benefits for services are sent to me, such checks are to be endorsed to Alaska Endodontic Specialists, LLC as payment on my account.

I understand that a billing charge of 10.0% (APR) is assessed on all delinquent accounts. I agree to inform Alaska Endodontic Specialist, LLC, in writing, of any change in my billing or mailing address as long as I have an outstanding balance. I accept responsibility for all costs incurred by Alaska Endodontic Specialists, LLC in collecting my debt owed to them.

I acknowledge that this office’s notice of privacy practices is available to me and is posted in the lobby.

Signature

Clear

Date

MM-DD-YY

reCAPTCHA

File Upload

Maximum upload size: 104.86MB