About Dr. Cohen Patient Care About Endodontics Treatment Your Appointments Contact Referring Doctors Reviews Patient Information Online Form Step 1 of 6 0% TELL US ABOUT YOURSELFName* First Last Sex*MaleFemaleAddress* Street Address City State / Province / Region ZIP / Postal Code Preferred Phone Number:*Preferred number is a ...*CellHomeOfficeAlternate Phone Number:Alternate number is a ...CellHomeOfficeEmail Address:* Enter Email Confirm Email Date of Birth* Date Format: MM slash DD slash YYYY Social Security Number:Occupation*Business / Employer Name*Name of General Dentist* TELL US ABOUT YOUR DENTAL SYMPTOMS Are you experiencing any pain at this time?*YesNoIf yes, can you locate where the pain originated? Please check all areas that apply:* Upper Lower Left Right Front Back When did you first notice the symptoms?*Did symptons occur suddenly or gradually?* Please check the word or words below that best describe your pain. 1=Mild _____ 10=Severe* 1 . 2 . 3 4 5 6 7 8 9 10 Frequency of pain:* Constant Intermittent Momentary Occasional Quality of pain:* Sharp Dull Throbbing Steady Are you taking pain killers or antibiotics for the tooth?* Yes No If yes, what is the name of the medication?Who prescribed the medication?When did you take the last dose?Is there anything you can do to relieve the pain?* Yes No If yes, what?Is there anything you do that causes the pain to increase?* Yes No If yes, what?When eating or drinking, is the tooth in question sensitive to: (Check all that apply.)* Heat Cold Sweets Does the tooth hurt when you bite down or chew?* Yes No Does it hurt if you press the gum tissue around this tooth?* Yes No Does a change in posture (lying down or bending over) cause your tooth to hurt?* Yes No Do you grind or clench your teeth?* Yes No If yes, do you wear a night guard, day guard, or Invisalign?Has a restoration (filling or crown) been placed on this tooth recently?* Yes No If so, when and by who?Prior to this appointment, has root canal therapy been started on this tooth?* Yes No If so, when and by who?Is there any thing else we should know about your teeth, gums or sinuses that would assist us in our diagnosis?*Signature of Patient (or Parent)*(Use your mouse or finger, if you are using a touch screen to write in the box below.)Date*Today's date. Date Format: MM slash DD slash YYYY TELL US ABOUT YOUR HEALTH How would you describe your health?*ExcellentGoodFairPoorWhen did you have your last physical examination?*Are you currently being treated for any illness or medical condition?* Yes No If yes, please describe.Name of physician:*Have you had surgery in the last 5 years?* Yes No What type of surgery did you have?When did you have this surgery?Are you taking blood thinners?* Yes No Have you had a stroke or heart attack?* Yes No Have you ever had any trouble with prolonged bleeding after surgery?* Yes No Do you wear a pacemaker or any other kind of prosthetic device?* Yes No Have you ever taken Fen-Phen, Redux or any other diet drugs?* Yes No Are you taking any medications, drugs or herbs at this time?* Yes No If yes, list the medications, drugs or herbs you are taking:Why are you taking these medications, drugs or herbs?Do you have to pre-medicate with antibiotics prior to any medical or dental procedures?* Yes No If yes, name of antibiotic.Have you ever had an unusual reaction to an esthetic or do you have any drug allergies?* Yes No If yes, please explain.Are you now or have you ever taken bisphosphonates (e.g., Fosamax, Boniva, Reclast, Evista)* Yes No If yes, please explain.Are you allergic to Latex?* Yes No Are you allergic to iodine?* Yes No Please select any present or past illness you have or have had:* Alcoholism Cancer Head/Neck Injuries Infectious Diseases Respiratory Allergies Diabetes Heart Disease Kidney Rheumatic Fever Anemia Drug Dependency Hepatitis Liver Sinusitis Asthma Epilepsy Herpes Mental Ulcers Blood Pressure Glaucoma Immuno Deficiency Migraine Venereal Disease If female, are you pregnant? Yes No Is there any other information that we should know about your health?*Signature of Patient (or Parent)*(Use your mouse or finger, if you are using a touch screen to write in the box below.)Date*Today's Date Date Format: MM slash DD slash YYYY Dental Insurance Information Do you have dential insurance?*YesNoDENTALPatient’s Name:*Name of Insured Person:(If different from patient)Insured’s Date of Birth (DOB)* Date Format: MM slash DD slash YYYY Insured’s Social Security Number (SSN)Relationship to Patient:* Self Spouse Domestic Partner Parent If insured is someone other than yourself, what is the name of their employer?Name of Insurance Company.Group Number:ID Number:Insurance Company Telephone Number:Please let us know if you have more than one dental insurance carrier. Provide details below: FINANCIAL AGREEMENT: While we try our best to accurately estimate your insurance benefits and co-payment, we cannot guarantee the final payment amounts, as they are decided by your insurance company. We collect your estimated co-payment at the time of service and then bill the insurance company for you. Your insurance company may take up to two months to process the claim and any portion not paid for by them is your responsibility. Please sign below to indicate you understand and agree to these conditions. Thank you. Signature of Patient (or Parent)*(Use your mouse or finger, if you are using a touch screen to write in the box below.)Date*Today's Date Date Format: MM slash DD slash YYYY Section Break Dear Patient: In an effort to provide you with flexible payment arrangements, we have expanded our payment policy. PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISITWe now offer the following payment options: Payment by cash Payment by check Payment by credit card Bill my insurance, I will provide a credit card to guarantee any amount not covered. *Our office is a fully accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa, MasterCard and Discover to automatically cover amounts not paid by your insurance.* Click here to download a Credit Card Payment Form. If paying via CareCredit please provide your account #: *CareCredit offers special financing and low monthly payment options, no up-front-costs, and no-prepayment penalties so you can start treatment at your time of need. We offer 6 or 12 month interest free plans at our office. Please ask the office manager for an application.* Appointment cancellation disclaimer If you are unable to keep your appointment, please inform us as soon as possible via phone or e-mail. Appointments for treatment which are cancelled with less than 24 hours notice will incur a $120.00 charge. I understand that a $120 broken appointment charge will be assessed to my account should I cancel within 24 hours of my scheduled appointment. Signature of Patient (or Parent)*(Use your mouse or finger, if you are using a touch screen to write in the box below.)Date*Today's Date Date Format: MM slash DD slash YYYY INFORMED CONSENT We are concerned not only about your dental health and endodontic treatment needs, but also about your right as a patient to make the treatment decision that you feel is best for you. Our commitment to you is to provide you with detailed and complete information about your dental needs as we diagnose them. We will share our diagnostic processes with you, and we invite and welcome all of your questions regarding our work with you. Towards this aim of a full, mutual sharing of information we feel it is important to advise you of the reasonably foreseeable risks of endodontic therapy. The following is important information you need to have in making your decision about treatment: Root canal therapy is a procedure designed to retain a tooth which may otherwise require extraction. Root canal therapy has a very high degree of success. However, it is a biological procedure and results cannot be guaranteed. Occasionally, and despite our best efforts, a tooth that has undergone non-surgical root canal therapy may require re-treatment or root canal surgery. We make special efforts to preserve the crowns of teeth we treat, but despite our best efforts occasionally a porcelain crown may fracture and require a new restoration. Even after root canal therapy, approximately 5% of endodontically treated teeth may eventually require extraction. Final restoration (crown) of the tooth that has undergone root canal therapy is essential for retention of the tooth. A Final restoration should be completed within 30 days of root canal therapy. Final restorations are provided by your restorative dentist. Signature of Patient (or Parent)*(Use your mouse or finger, if you are using a touch screen to write in the box below.)Date*Today's Date Date Format: MM slash DD slash YYYY CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.