Online Forms

Electronic Forms

​​​​​​​

Patient Information Form

Referring Dentist*

Today's Date*

Pharmacy Name/Location*

PATIENT INFORMATION

Patients LEGAL Name (Last)*​​​​​​​

Patients LEGAL Name (First)*​​​​​​​

Address*

City

State

Zip Code

CellPhone Number*

Home Number

Sex*

Age*

Date of Birth*

Social Security #

Insured Employer

Work Number

Email Address

Legal Guadian's Name (if applicable)

INSURANCE INFORMATION

Dental Plan Name

Phone Number

Policy Holder Name

Date of Birth

Member ID#

Group #

Secondary Dental Plan

Phone Number

Policy Holder Name

Date of Birth

Member ID#

Group #

Medical Plan Name

Phone Number

Policy Holder Name

Date of Birth

Member ID#

Group #

Health History Form

Patient Name*

Birth Date*

I. Choose the appropriate answer (Leave Blank if you do not understand the question)

Is your general health good?*

Has there been a change in your health within the last year?*

Have you been hospitalized or had a serious illness in the last three years?*

If yes, why?

Are you being treated by a physician now?*

For what?

Date of last medical exam*

Date of last dental exam*

Have you had problems with prior dental treatment?*

Are you experiencing any pain now?*


II. Have you ever experienced:

Chest Pain (Angina)*

Swollen Ankles*

Shortness of breath*

Recent weight loss, fever or night sweats*

Persistent cough, coughing up blood*

Bleeding problems, bruising easily*

Sinus problems*

Difficulty swallowing*

Diarrhea, constipation, blood in stools*

Frequent vomiting, nausea*

Difficulty urinating, blood in urine*

Dizziness*

Ringing in ears*

Headaches*

Fainting spells*

Blurred Vision*

Seizures*

Excessive Thirst*

Frequent Urination*

Dry mouth*

Jaundice*

Joint Pain, stiffness*


III. Do you have or have you had:

Heart Disease*

Heart Attack, Heart Defects*

Heart Murmurs*

Rheumatic Fever*

Stroke, hardening of arteries*

High Blood Pressure*

Asthma, TB, Emphysema, other Lung Disease*

Hepatitis, other Liver Disease*

Stomach problems, ulcers*

Family History of Diabetes, Heart Problem, Tumors*

Psychiatric Care*

Radiation Treatments*

Chemotherapy*

Prosthetic Heart Valve*

Artificial Joint*

Arthritis, Rheumatism*

HIV+*

Tumors, Cancer*

Eye Disease, Skin Disease*

Anemia*

VD (Syphilis/Gonorrhea)*

Herpes*

Kidney or Bladder Disease*

Thyroid or Adrenal Disease*

Diabetes*

Hospitalization*

Blood Transfusions*

Surgeries*

Pacemaker*

Contact Lenses*


IV. Allergies:

Sulfa or Sulfur*

Penicillin*

Other Antibiotics*

Latex*

Foods or Chemicals*


V. Are you taking:

Bisphosphonate Drugs such as Fosamax?*

Recreational Drugs*

Drugs, Medications, Over-the-Counter Medications (including Aspirin), or Natural remedies?*

Tobacco in any form*

Alcohol*

Antibiotics*

Pain Medications*


VII. All Patients

Do you have or have had any other diseases or medical problems NOT listed on this form?*

Do you require premedication with an Antibiotic prior to dental treatment?*


VIII. Women Only

Are you or could you be pregnant or nursing?

Taking any birth control pills?

Printed Name*

Initials (E-Signature)*

Date*

Medical Release of Records

I authorize the release of my dental records, CBCT, and/or X-rays, (Please note CBCT scans will be sent via mail only due to large file size.)

To

Address

Phone Number

Fax Number

Email Address

Printed Name

Initials (E-Signature)

Date

Health/COVID-19 Questionnaire

1. Do you presently have any of the following respiratory symptoms?

Cough

Fever

Shortness of breath

Sore Throat

2. Have you or any immediate family member had any of the following respiratory symptoms in the last 2 weeks?

Cough

Fever

Shortness of breath

Sore Throat

3. Have you traveled internationally within the last 2 weeks to any of the following countries?

4. Have you traveled domestically within the last 2 weeks?

If yes, what states were visited?

Printed Name

Initials (E-Signature)

Date

COVID-19 Consent Form

As everyone knows, the World Health Organization identified Coronavirus, or COVID-19, like a pandemic. Many countries and states have moved to slow its spread through quarantines, social isolation, business shutdowns, and other measures.

The American Dental Association recommends a two-fold strategy: 1) it is up to the dentists to make well-informed decisions about their patients and practices; and, (2) that elective or non-emergency dental procedures be postponed.

The Arizona State Board of Dental Examiners supports the ADA’s position and recommended additional protocols found on the back of this page.

As of today, none of the Canyon Ridge Endodontics doctors or staff has exhibited any coronavirus symptoms; however, we have not been pre-screened for COVID-19 and cannot guarantee that either we or our office are Coronavirus-free.

Not only does Canyon Ridge Endodontics follow the expected hygiene protocols, but we have increased patient safety measures since the outbreak.

Given this knowledge, and knowing that I possibly could contract COVID-19 at Canyon Ridge Endodontics through its doctors, staff, facility, or from other patients, I nevertheless wish to continue with my elective dental treatment.

I have read this page and the content on the reverse side as well.

Printed Name

Initials (E-Signature)

Date

Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

I understand that under the Health Insurance & Portability Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that information can and will be used to:

1. Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations such as quality assessments and physician certifications.


I have received, read, and understand your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that your organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed. I also understand that you are not required to agree to my requested restrictions, but if you agree then you are bound to abide by such restrictions.


PAYMENT POLICY

Your insurance policy represents a contract between YOU and your insurance company. Patient portions of dental treatment are DUE AT TIME OF SERVICES. We do offer several methods of payment, and if desired we will assist you with the option of third-party financing. Your insurance carrier does not issue guarantees of coverage and it is your insurance company that makes the final determination of benefits. Therefore, we cannot guarantee any patient portion amounts. As a courtesy to you, we will bill your insurance, but YOU ARE ULTIMATELY RESPONSIBLE for all charges incurred in our office. WE RESERVE THE RIGHT TO BILL YOU FOR ANY REMAINING BALANCES DUE TO INSURANCE DELAYS OR DENIAL OF CLAIMS.


RELEASE OF INFORMATION

I authorize the release of information, including diagnosis, records, and insurance. This information may be released to:

Name

Relationship

Name

Relationship

Name

Relationship

Patient Name

Relationship to Patient

Patient Signature

Date