Bethesda-Chevy Chase Root Canal Specialists, LLC

Practice Limited to Endodontics

Thank you for contacting our office, and welcome to our practice. Please complete the attached three-page registration form and bring it with you to your appointment.*

 In addition, please follow these guidelines in preparation for your visit:

 1) Please bring your referral information and x-rays, if any, from your restorative dentist.

 2) Eat breakfast or lunch before your appointment to ensure a normal blood glucose level. DO NOT drink caffeinated drinks, such as regular coffee.

 3) Arrive 15 minutes early to complete a few additional forms. Bring a complete list of all medications and dosages with you.

 4) Take all of your routine medications, including aspirin therapy, if applicable. However, do not take medication for discomfort (i.e., ibuprofen, Advil, Motrin, Aleve, etc.) prior to the first visit because it may mask symptoms and hinder diagnosis.

 5) If you require prophylactic antibiotics before dental visits for a prosthetic heart valve or orthopedic prosthesis (artificial hip, knee, elbow, etc.), please call our office for instructions. If you've already discussed this with us, you do not need to call again.

 6) Please let us know if you take Coumadin (warfarin sodium), so we can contact your physician in advance to receive your current INR readings.

 7) Our office hours are from 8:30am until 5:00pm, Monday-Friday. Occasionally, last minute emergency patients can delay our schedule, so please allow a little extra time for your appointment. We value your time and will try to keep you updated when delays occur.

 8) All patients under the age of 18 must be accompanied on each visit by their parent or legal guardian.

 9) Please explore our website at www.endocc.com to learn more.

 10) Insurance: Endodontic fees are based on the complexity of the procedures.

We will make every effort to help you receive reimbursement by your insurance carrier, so please bring your dental and medical insurance information with you. We welcome any questions you may have about payments and insurance benefits. 

 

We look forward to being of service to you. If you have any questions, please don't hesitate to call us.

 *Completion of these forms does not constitute the establishment of a doctor-patient relationship.

 

Patient Registration and Health History Form

Patient Information
Name *
Name
Address
Address
Primary Phone Number *
Primary Phone Number
Secondary Phone Number
Secondary Phone Number
Physician's Phone
Physician's Phone
Emergency Contact
Relationship
Emergency Phone Number
Emergency Phone Number
Insurance Information
Do you have dental insurance? *
Reason for Visit
Medical History
Please answer the following questions to the best of your knowledge. Although endodontists primarily treat the mouth area, medical problems or medications could have a significant impact on your dental treatment. Your answers are confidential.
Are you in good health? *
Are you under the care of a physician? *
Have you had any illness, operation, or been hospitalized in the past five years? *
Check all that apply: *
Medication
Are you taking any of the following medications (please check)? *
Allergies *
Women
Are you pregnant?
Is there a possibility of pregnancy?
Are you nursing?
Are you taking birth control pills?
Antibiotics, such as penicillin, may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control if antibiotics are prescribed.
All Patients
Have you been told by your physician to take antibiotics prior to dental treatment? *
Is there any health condition which the doctor should know about? *
Do you wish to speak to the doctor privately about anything? *
Consent
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my endodontist, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. I understand that I am responsible for notifying my endodontist of any medical changes upon each visit.
Authorization
I authorize my endodontist and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. If medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.
Acknowledgement of Receipt of Notice of Privacy Practice
Drs. George Jong, Anastasia Mischenko, Wonhee Lee, and Bethesda-Chevy Chase Root Canal Specialists, LLC will only use and disclose your personal health information to treat you and to receive payment for the care we provide and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies about your personal health information. The terms of the notice may change with time and we will always post the current notice at our facilities, on our website, and have copies available for distribution.