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MICHANOWICZ ENDODONTICS, INC.
DENTAL INSURANCE CO._________________________
Subscriber’s birth date ____/____/____
Phone # _________________ SSN _______________
Group # __________________
Cell # ___________________ Work________________ SECONDARY INS. CO._____________________________
Birth date ___/___/___ Age: ___ Sex: __M __ F
Subscriber’s birth date ____/____/____
Emergency Contact Name and Phone #
Group # __________________
Check: If you have any of these conditions, and need
I authorize the release of any dental information necessary
antibiotics before dental treatment.
to process my claims, and agree to pay any portion of what
my insurance does not cover. All arrangements must be
____MITRAL VALVE PROLAPSE
made in advance.
Family Dentist Name _________________________Who referred you to our office?_____________________
Are you pregnant? ______ How many weeks/months? _______ Are you taking oral contraceptives? __yes __no
CIRCLE MEDICATIONS THAT YOU ARE ALLERGIC OR SENSITIVE TOO:
Penicillin Sulfa Keflex Erythromycin Tetracycline Local Anesthetic Codeine Narcotics Tylenol
Aspirin Latex Nitrous Oxide Valium Ibuprofen Foods Other________________________________________
PLEASE LIST All YOUR MEDICATIONS: _______________________________________________
CHECK IF YOU HAVE OR HAD ANY OF THE FOLLOWING:
__Low Blood Pressure
__Shortness of Breath
__Swelling of feet/hands
__High Blood Pressure
__Pain in Jaw Joints
__Frequent Cough __Kidney Disease __Recent Weight Loss
DESCRIPTION OF DENTAL PAIN (Check all that APPLY TODAY)
___Bubble on the gum
___Gums are sore/bleeding
___Tooth feels loose ___ Change in altitude causes pain
___Hot liquids/foods cause pain
___Tooth keeps you awake
___ Cold liquids/foods cause pain
___Pain comes & goes
___Tooth sore to touch or chew
___Previous root canal
___ Dull ache
___Sharp/shooting pain ____Jaw pain
___Sweets cause pain ____Symptom Free
Persons Involved in Care:
We may disclose your health information to a family member, or any person responsible for your care. In the event of an emergency, we
will disclose information based on our professional judgment. We will use our judgment and experience to make reasonable inferences of your best interest in allowing
a person to pick up prescriptions, medical supplies, x-rays, or other health information.
Required by Law:
We may disclose information required by law; such to the extent necessary to avert a serious health or safety threat to you or others. We may
disclose information to military and federal officials required for intelligence, and other national security activities. Appointment Reminders:
We may disclose your health information to provide you with an appointment reminder such as voicemail and letters. Patient Rights:
You have the right to get copies of your health information; this request must be in writing. Disclosure Accounting:
You have the right to receive a list of instances in which we disclosed your health information. Restrictions:
You have the right to request that we place additional restrictions on our use or disclosure of you health information. We do not have to comply. Alternative Communications:
You have the right to request that we communicate with you about your health information by alternative means/locations. This
request must be in writing. Amendment:
You have the right to request that we amend your health information, this request and explanation must be in writing. We may deny the request.
We support your privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us/U.S. Department of Health/Services.
We are required by law to maintain the privacy of, and provide you with this written notice of our legal duties and privacy practices. Contact Officer: Angel Michanowicz (814) 696-1800 Fax (814) 696-5950
Signature below is only acknowledgement that you received this Notice of our Privacy Practices:
ENDODONTIC CONSENT AND INFORMATION
This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable to the planned endodontic
therapy performed by Dr. Michanowicz and any assistants required. I agree to the use of local anesthesia depending on the judgment of the
endodontist. I understand the endodontist will consult with me prior to the administration of any sedation. Complications of root canal therapy and
anesthesia may include swelling, pain, trismus (restricted jaw opening), exacerbation of temporomandibular joint disorders, infection, sinus
involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely permanent. I understand that it is
my responsibility to report any symptoms to the endodontist immediately.
RISKS MORE SPECIFIC TO ENDODONTIC THERAPY
: The risks include the possibility of instruments broken within the root canals;
perforations (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth
structure in gaining access to canals, and fractured teeth. During treatment complications may be discovered which make treatment impossible, or
which may require dental surgery. These complications may include the following: blocked canals due to fillings or prior treatment, natural
calcifications, broken instruments, curved roots, periodontal disease (gum disease), splits or fracture of teeth, and perforation of the pulp chamber and
root canal system. I UNDERSTAND THAT I AM LEAVING THIS OFFICE WITH A TEMPORARY FILLING, AND THE PERMANENT RESTORATION (FILLING, POST & CORE, CROWN, ONLAY ETC.) WILL BE COMPLETED
BY MY GENREAL DENTIST. THE RESTORATION IS NECESSARY FOR THE SUCCESS OF THE ROOT CANAL TREATMENT.
I, the undersigned, certify that the information on both pages are correct and accurate.
I understand that root canal therapy is a procedure to attempt to save a tooth which may otherwise require extraction. Root canal therapy has a very
high degree of clinical success, results cannot be guaranteed and healing is influenced by many factors. On rare occasions, a tooth which has root
canal treatment may require retreatment, surgical correction, or even extraction. Signature of Patient/Parent
________ Dr. Michanowicz_____________________
Immune Response Testing of Electrospun Polymers: An Important Consideration in the Evaluation of Biomaterials Matthew J. Smith1, Donna C. Smith2, Kimber L. White, Jr.2, and Gary L. Bowlin1 1Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia USA 2Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia USA Disclosu
Travel Clinic Travel Clinics For Safe International Travel: Prevention Pays Airlines have made the world smaller, countries closer, and tropical diseases easier to contract. The last decade of international business opportunities have led to a dramatic increase in more foreign travel by Americans. There is also a new trend to travel to out of the way places to "get back to nature