JCV Endodontics logo featuring stylised J and C letterforms forming a tooth-like symbol

REGISTRATION FORM

To get started on your journey and personalised endodontic care, please fill out the registration form below.

New Patient Registration Form

Please use this form to register for treatment at JCV. This form will provide us with important details regarding your contact information and any health details. These details are essential before proceeding with endodontic treatment.

Patient Information

Patient Contact
Private & Confidential Medical Information
Certain medical conditions and medication use require special precautions during dental treatment; so please answer the following as accurately as possible for your safety.
Please tick any medical conditions you currently have or have had in the past:
PLEASE NOTE: IT IS IMPORTANT YOU ADVISE YOUR ENDODONTIST OF ANY CHANGES TO YOUR HEALTH BEFORE EACH VISIT
Emergency Contact
Important Information About Your Endodontic Treatment
Endodontic treatment outcomes vary between patients and individual teeth. While treatment is undertaken with the aim of managing disease and retaining the affected tooth where clinically appropriate, a particular outcome cannot be guaranteed. The likely outcome of treatment can be influenced by several factors, including the condition of the tooth and surrounding tissues, previous dental treatment, the nature and extent of infection or inflammation, root canal anatomy, the restorability of the tooth, general health, and how the tooth responds to treatment. In some circumstances, a tooth may require additional treatment, such as endodontic retreatment, endodontic surgery or further restorative care. In some cases, extraction may ultimately be required. Your endodontist will assess your individual circumstances and discuss the proposed treatment, relevant risks, alternatives and expected outcomes with you before treatment proceeds..

Treatment Fees

As a general guide, endodontic treatment at JCV Endodontics currently ranges from $1,900 to $3,800, depending on the treatment required and the complexity of the individual case.

Your actual treatment fee may differ from this indicative range. Where practicable, you will be provided with an individual estimate before treatment begins.

Private health insurance benefits vary between policies and insurers and should be confirmed directly with your health fund.

See our root canal cost in Perth page for more detail on what affects treatment fees.

Payment Information
PLEASE NOTE: Payment in full is required on the day of your treatment. EFTPOS, credit card (AMEX, Mastercard, Visa) & HICAPS facilities are available. If for any reason, you cannot pay the account in full on the day, please inform us before your appointment. An overdue account will incur additional charges.

Important: JCV Endodontics collects the personal and health information you provide in this form so that we can identify you, manage your referral and appointments, assess matters relevant to your dental care, provide endodontic services, communicate with you and your referring or treating health practitioners where appropriate, and administer accounts and health fund matters.

Some of the information requested is health information and is considered sensitive information under Australian privacy law.

We may disclose relevant information to health practitioners involved in your care, diagnostic providers, anaesthetists or other healthcare providers involved in your treatment, and service providers that assist us in operating the practice, where permitted by law and appropriate to your care.

If you do not provide information that is reasonably required for your care, we may be unable to properly assess your circumstances or provide certain services.

Information about how JCV Endodontics collects, holds, uses and discloses personal information, how you may request access or correction, and how you may make a privacy complaint is available in our Privacy Policy. If you prefer not to provide health information through this online form, please contact JCV Endodontics to discuss an alternative way of providing the information.

Would you like to contact us?

Are you choosing us for your root canal treatment? Please use our registration form to provide us with important details regarding your contact information and health details.

CONTACT US