Medical History & Consent

Name*

Address*

Mobile No.*

Date of Birth*

Occupation*

Email*

Dentist*

Doctor

Are you Currently

Under treatment by a doctor, specialist or hospital *

Under treatment by a doctor, specialist or hospital*

Yes
No

Seeing a Doctor Comments

Taking medicine, drugs or tablets including steroids*

Yes
No

Medicine / Drugs / Tablets Comments

Pregnant*

Yes
No

Pregnant Comments

Did you, as a child or since, have

Liver disease (hepatitis, jaundice) kidney disease*

Yes
No

Liver disease Comments

Heart attack, angina, high blood pressure, stroke*

Yes
No

Heart attack Comments

Bronchitis, asthma or emphysema*

Yes
No

Bronchitis Comments

Diabetes, or does anyone in your family*

Yes
No

Diabetes Comments

Brain Surgery*

Yes
No

Brain Surgery Comments

Heart surgery*

Yes
No

Heart Surgery Comments

Joint replacement or other implant*

Yes
No

Joint replacement Comments

Bruising or persistent bleeding following injury*

Yes
No

Bruising Comments

Allergies to any medicine, foodstuffs, substances*

Yes
No

Allergies Comments

A bad reaction to general or local anaesthetic*

Yes
No

Reaction Comments

Hay fever or eczema*

Yes
No

Hay fever or eczema Comments

Fainting attacks, blackouts, epilepsy*

Yes
No

Fainting attacks, blackouts, epilepsy Comments

Anxiety or depression*

Yes
No

Anxiety or depression Comments

Any infectious diseases including H.I.V Hepatitis B*

Yes
No

infectious diseases Comments

Treatment that required you to be in hospital*

Yes
No

Treatment that required you to be in hospital Comments

Any other serious illness*

Yes
No

Any other serious illness Comments

Are you carrying a warning card*

Yes
No

Are you carrying a warning card Comments

Other

Other aspects of your health not included above that you think I should know

Treatment Consent

Current techniques in Endodontics enable us to perform root canal therapy with no more discomfort to the patient than that experienced in normal dental procedures.

Treatment is recommended when we believe that the prognosis is favourable. In fact 95% of treated teeth heal with routine treatment. Occasionally treatment fails, in these cases the tooth may respond to other procedures. However in a small percentage of cases in spite of our best efforts to save the tooth, it may not respond and extraction may be necessary. Therefore guarantees cannot be given.

A number of visits may be required per tooth and this will depend on the complexity of the case and the response to treatment. The treatment plan and schedule will be discussed prior to treatment.

Every effort is made to treat each case in the best possible manner however, in spite of this occasionally the following may occur which may alter treatment advised:

A flare up causing pain and / or swelling
Perforation of the root with instruments
Separation of instrument in canal which may cause obstruction
Tooth or root fracture
Inability to instrument the canal to the end of the root
Over extension of filling material through the root of the tooth
Extrusion of irrigation solutions through the apex of the tooth
Persistent tenderness may remain after treatment

In the unlikely event of any of the above occurring during treatment you shall be informed of the possible consequences and if further treatment is advisable or necessary.

Fees for root canal treatment are displayed in the waiting room. Payment should be made at the end of each visit. The fees quoted do not include the cost of surgical treatment. Should the need for surgery arise at a later date, the fees for this will be discussed. Persistent breaking of appointments without notice will result in additional fees.

This practice is limited to endodontic procedures and you are responsible for making arrangements with your referring dentist for the final restoration on the crown of the tooth. Delay in attending your dentist may cause loss of the treated tooth through further decay, leakage or fracture.

The above has been explained to me and I understand that the treatment cannot be guaranteed. I will be financially responsible for treatment. I understand that the fees are to be paid in full upon completion of treatment of each tooth. I understand that I am responsible for arrangements to return to my dentist to have the permanent restoration placed on the tooth.

GDPR Consent

Here at Waterford Endodontics we take your privacy seriously. We only use your personal information to provide our treatment and services to you and to administer your account.

We seek your consent to obtain, process and store personal data for the purpose of providing you with dental treatment, safely and to the highest standards. Without your agreement to this process it may not be possible to undertake treatment.

Following completion of treatment we will return a report and relevant radiographs to your referring General Dental Practitioner or Dental Specialist. We do not pass your details on to other parties for unsolicited marketing purposes.

Please be aware that other messages you may currently receive from us, such as appointment reminders and recalls, are not considered promotional activity and are therefore excluded from being covered by this request for consent. Should you wish to stop receiving these messages, then you will need to express your desire to opt-out directly to our reception staff.

If you do provide consent, you may subsequently withdraw your consent at any time by contacting the practice directly.

You have access to a copy of your personal data upon written request and the right to have data rectified if incorrect. You are legally entitled to a photocopy of your personal data upon written request. You also have the right to have any inaccuracies in your data rectified and to have the data erased. You will be provided with a photocopy of radiographs in response to an access request.

The data compliance officer in this practice is Dr Mary Egan.

If you have a complaint or concern with any aspect of how we process your personal information we would hope that you would notify Dr Mary Egan in the first place. You retain the right to make a complaint to the Data Protection Commissioner at all times.

Should you wish to know further details please refer to our Practice Privacy Policy.

I consent for my details to be used for the purposes outlined above:

Consent

The information submitted is accurate and I agree to the GDPR and Treatment consent.

Patient History

Are you Currently

Did you, as a child or since, have

Other

Treatment Consent

GDPR Consent

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