Online Forms
Please note that Wichita Falls Endodontics takes your care and privacy very seriously. The Health History, Consent for Treatment, and Financial Policy forms all need to be completed and signed prior to treatment.
Our office has provided these PDF files so that you can fill them out and print them within the privacy of your home. Please make sure each form is accurately filled out, and please include all medications you are currently taking.
If you do not have a printer or would feel more comfortable completing the forms at our office, please arrive 30 minutes early to your appointment and copies will be provided to you.
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Patient Information & Health History - This form includes health history and insurance information. |
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Consent for Treatment - This form reviews endodontic treatment and risks that are associated with the procedure. |
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Financial Policy - This form reviews the financial obligation that is expected by Wichita Falls Endodontics. |
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HIPPA Privacy Notification - This form reviews our privacy policy and informs the patient of their health rights. |
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What to Expect Following Treatment - This form provides some helpful tips and suggestions for after the procedure. |
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Referral Form -This form can be downloaded and filled out electronically. A referral form is not required for the patient to schedule an appointment. |
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Consultation Policy -This form outlines our Consultation fees for patients with / without insurance; it can be downloaded and filled out. |
