<p> Informed Consent</p><p>I understand Root Canal Therapy is a procedure to retain a tooth which may otherwise require extraction. Although Root Canal Therapy has a very high degree of clinical success, it is still a biological procedure so it cannot be guaranteed. Occasionally a tooth which has had Root Canal Therapy may require Retreatment, Surgery, or even extraction. </p><p>Only the Root Canal will be performed in this office. I am to return to my general dentist within 2 to 4 weeks after the Root Canal Treatment has been performed for a permanent restoration (filling/crown). Dr. Ogden will only be placing a temporary restoration in the tooth at the end of the procedure. </p><p>I also understand that if I have a ceramic and/or porcelain restoration (crown) it can fracture during treatment. I am aware that I am responsible for the repair or replacement that may be required once completed. </p><p>Signature: Date: </p><p>(Patient, Parent, or Guardian)</p><p>Patient Charts are in an unlocked filing cabinet available to the staff of Ogden Endodontics and Microsurgery; our office is HIPPA compliant and operates above the standard of care in accordance with OSHA and ADA guidelines.</p><p>Signature: Date: </p><p>(Patient, Parent, or Guardian)</p><p>I acknowledge that I have either read or received a copy of the Notice of Privacy Practice. </p><p>I consent to have Dr. Ogden and staff to contact my dentist as needed for treatment, to file insurance, and contact whomever is needed to collect the payment for my account. I authorize the release of any information necessary for treatment and to process any insurance claims. </p><p>I understand that the office will file the insurance with the information given at the time of treatment. I also accept full responsibility for the payment of any service which are performed by Dr. Ogden and agree to pay for them in full at the time of service. Any balance left over after 30 days becomes the patient’s responsibility and will start to occur finance charges at the rate of 1.5% per month (18% apr). Please remember that we can only file with the information provided and it is your responsibility to make sure that it is valid.</p><p>Signature: Date: </p><p>(Patient, Parent, or Guardian) For any questions or concerns please contact Lora Zickau (Privacy Officer) 757-499- 9839 Ogden Endodontics 351 Edwin Drive. Suite 103, Virginia Beach, VA 23462</p>