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Prior to your visit

For your convenience, you may print and complete the following required paperwork prior to your visit:

Health History Form

Alerts your doctor as to any medical conditions which may affect your treatment.

Privacy Policy Notification

Implements our obligation to protect the privacy of individually identifiable health information that we create, receive, or maintain as a health care provider.

Please review the following information prior to your appointment:

Financial

Since most of our endodontic specialty care is completed in one visit, all fees are due at the time of treatment. As a courtesy to our patients who have dental insurance, our reception staff will inquire about your eligibility, benefit availability and deductible. We will estimate your co-payment which is due at the time of treatment. You will receive a bill for any remaining balance. If there is an overpayment, we will promptly issue a refund check. Ultimately, a patient is responsible for their account; not their insurance company. Please feel free to ask our staff any insurance related questions.

Premedication

Patients who require premedication prior to dental treatment should take their antibiotic regimen as directed before any treatment visits. Premedication is not required for a consultation or recall visit.

Minors

Patients under the age of eighteen must be accompanied by a parent or legal guardian. This adult will be asked to complete a health history and consent form for their minor.

Section 1557 of the ACA
We will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing.



These forms are in Portable Document Format (.pdf) - If you cannot open them on your computer, please click the link below to download the free Adobe Reader:

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NH Endodontics Doctors