FIRST VISIT.....
Your initial appointment will begin with a consultation. This includes a thorough
examination and testing of any potentially affected teeth, which facilitates an accurate
diagnosis. We will then explain your diagnosis to you, including all possible treatment
options. Please let us know what you would like to accomplish on your first visit so that
we can schedule the appropriate amount of time.
A complex medical history or treatment plan may require an additional appointment for
further evaluation on another day, before treatment can be provided.
Your initial appointment will begin with a consultation. This includes a thorough
examination and testing of any potentially affected teeth, which facilitates an accurate
diagnosis. We will then explain your diagnosis to you, including all possible treatment
options. Please let us know what you would like to accomplish on your first visit so that
we can schedule the appropriate amount of time.
A complex medical history or treatment plan may require an additional appointment for
further evaluation on another day, before treatment can be provided.
Please alert the office if you have a medical condition that may be of concern prior to treatment
(i.e. diabetes, high blood pressure, artificial heart valves and joints, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.) or require
medication prior to certain dental procedures ( antibiotics for pre-medication).
(i.e. diabetes, high blood pressure, artificial heart valves and joints, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.) or require
medication prior to certain dental procedures ( antibiotics for pre-medication).
| X-Rays The standard of care requires that x-rays be taken for proper diagnosis and treatment of endodontic (root canal) problems. PLEASE BE ASSURED that with the digital technology we use, the x-rays we take expose our patients to minimal radiation (up to 90% less radiation). These images are obtained instantly and will be used to explain your diagnosis. If your previous dentist has taken recent x-rays (within 6-months), you may request that they forward them to our office. If additional films are necessary, they can be taken at our facility. IF YOU ARE PREGNANT, OR YOU SUSPECT YOU MAY BE PREGNANT, PLEASE INFORM THE DOCTOR AND THE STAFF AT THE TIME OF YOUR APPOINTMENT. |
| IMPORTANT: A parent or guardian must accompany all patients under 18 at the consultation visit. |
Please assist us by providing the following information at the time of your consultation:
•A referral slip and any X-rays from your referring doctor (if applicable)
•List of medications you are presently taking.
•If you have dental insurance, please bring your insurance ID card. This will save time and allow us to
assist you in processing any claims. It is your responsibility to provide current insurance information if you
want the office to file a claim on your behalf.
Date_________
Introducing ________________________
for Endodontic consideration of__________
Reason for referral:
Proceed with root canal therapy ____
Proceed with Consultation ____
Cone Beam Scan ____
Leave post space ____
Please call after seeing patient ____
Dr Signature: ____________________
Introducing ________________________
for Endodontic consideration of__________
Reason for referral:
Proceed with root canal therapy ____
Proceed with Consultation ____
Cone Beam Scan ____
Leave post space ____
Please call after seeing patient ____
Dr Signature: ____________________
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| GRANITE STATE ENDODONTICS Dr. Aneesa Al-Khalidi D.M.D 505 West Hollis Street ~ Suite 104 Nashua, NH 03062 603-883-3636 |
