Registration Form

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

Date of Birth (DD/MM/YYYY)

Name of Private Health Fund

Patient Series Number

Check this box if the treatment is going to be paid by a third party Check this box if you are completing this form on behalf of the patient

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.

What is your medical doctor's (GP) name and suburb?

Please tick any medical conditions you currently have or have had in the past:

Other medical conditions (please specify):

Do you have any medical conditions that you wish to discuss with the doctor in private?

Yes No

Have you had any recent surgery within the last 2 years?

Yes No

Please list any medication you are currently taking

Have you ever had an unusual reaction to Anaesthetic

Yes No

Please list any allergies (Penicillin, Latex, Medication) or write "None" if this is the case

Do you bruise or bleed easily?

Yes No

Are you pregnant?

Yes No N/A

Are you breastfeeding?

Yes No N/A

Any additional information that we need to know about your health?

Are there any aspects of the root canal treatment that concern you?

PLEASE NOTE: IT IS IMPORTANT YOU ADVISE YOUR ENDODONTIST OF ANY CHANGES TO YOUR HEALTH BEFORE EACH VISIT

Emergency Contact Full Name

Emergency Contact Phone Number

Endodontic Treatment

PLEASE TAKE THE TIME TO READ THE FOLLOWING PARAGRAPH Routine endodontic (root canal) treatment has a high success rate, with studies indicating outcomes between 90% and 95%. However, cases referred to an Endodontist are typically non-routine, which makes treatment outcomes more difficult to predict. Occasionally, a tooth that has previously undergone endodontic treatment may require retreatment, surgical intervention, or, in rare cases, extraction. Several factors may contribute to complications or treatment failure, including the tooth’s initial condition, previous treatments, the type of bacterial infection, anatomical challenges, the limitations of available instruments and procedures, the patient’s general health, and their level of cooperation throughout treatment. The cost of treatment typically ranges from $1,900 to $3,800, depending on the complexity of the case. For a personalised estimate, we recommend discussing this directly with the Endodontist prior to beginning treatment.

I have answered these questions honestly and to the best of my knowledge

I have read carefully and understand the statement above

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.

REGISTRATION FORM

New Patient Registration Form

Patient Information

Would you like to contact us?

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