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Drrootcanal.com

MICHANOWICZ ENDODONTICS
MICHANOWICZ ENDODONTICS, INC.
Patient ________________________________________
DENTAL INSURANCE CO._________________________
Subscriber____________________________________
Address _______________________________________
Subscriber’s birth date ____/____/____
______________________________________________
SSN ____________________________
Employer _____________________________________
Phone # _________________ SSN _______________
Group # __________________
Cell # ___________________ Work________________ SECONDARY INS. CO._____________________________
Subscriber____________________________________
Birth date ___/___/___ Age: ___ Sex: __M __ F
Subscriber’s birth date ____/____/____
SSN _________________________________________
Employer _____________________________________
Employer _____________________________________
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.
____ARTIFICAL VALVE/STENTS
____HIP/KNEE/JOINT REPLACMENT
Signature: ________________________Date:_________
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:

__Aids (HIV) __Bruise easily __Glaucoma __Low Blood Pressure __Rheumatic Fever
__Allergies/Sinus __Cancer
__Heart Conditions __Lung Disease __Shortness of Breath
__Anemia/Sickle Cell __Chemotherapy/Rad __Heart Murmur __MS
__Stroke
__Arthritis __Cortisone
__Hemophilia __Nervousness __Swelling of feet/hands
__Asthma __Diabetes __Hepatitis __Organ Transplant __Thyroid Disease
__Alzheimer’s __Drug Addiction __Herpes
__Other__________ __Tuberculosis
__Blood Disease __Emphysema __High Blood Pressure __Pain in Jaw Joints __Ulcers
__Blood Transfusion __Epilepsy/Seizures __Hypoglycemia __Psychiatric Care __Venereal Disease
__Frequent Cough __Kidney Disease __Recent Weight Loss

(TURN OVER)

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
___Constant pain ___Previous root canal ___Throbbing pain
___ Dull ache
___Sharp/shooting pain ____Jaw pain
___Ear pain ___Sweets cause pain ____Symptom Free
HIPAA PRIVACY POLICY
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:

PRINT________________________________________________SIGNATURE__________________________________________DATE: ______________

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__________________________ Date________ Dr. Michanowicz_____________________

Source: http://www.drrootcanal.com/PatientHealthHistory2011.pdf

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