Endodontic Emergency Contact Information Form

Patient Information

• Full Name: ____________________________
• Date of Birth: _________________________
• Primary Phone: ________________________
• Secondary Phone: ______________________
• Email: _______________________________

Emergency Contact Information

• Primary Contact Name: __________________
• Relationship to Patient: ________________
• Phone (Home): ________________________
• Phone (Mobile): _______________________

Secondary Emergency Contact

• Name: _______________________________
• Relationship to Patient: ________________
• Phone: ______________________________

Current Medications

• List all current medications: _____________
• Drug allergies: ________________________

Medical History

• Primary Care Physician: _________________
• Phone: _______________________________
• Relevant medical conditions: ____________

Dental Insurance Information

• Primary Insurance: _____________________
• Policy Number: ________________________
• Group Number: ________________________

Consent for Emergency Treatment

I hereby authorize the endodontist and staff to perform necessary emergency endodontic treatment. I understand that root canal therapy and related procedures will be performed in accordance with accepted methods of clinical practice. I acknowledge that no guarantees have been made concerning the results of the treatment.

Signature: ___________________________ Date: _______________________________

Office Use Only

• Date Received: _______________________
• Reviewed By: ________________________
• Notes: _____________________________