Capital Endodontics

(608) 442-3300

Monday – Friday 7:30am–4:30pm

Patient Forms

The following forms can filled out and submitted electronically prior to your appointment or printed and submitted at the time of your appointment. If you would prefer to fill them out upon check in, please plan to arrive at least 15 minutes in advance of your appointment to complete forms.


INSTRUCTIONS: To submit forms electronically, please download and complete.
Then save forms and email to:


Adult Registration Form

Child Registration Form

Health Information Form

The following forms can be reviewed and/or printed ahead of time, but will be signed at the time of your appointment:


Acknowledgement of Financial Policy

Notice of Privacy Acknowledgement

Patient Consent for Endodontic Procedures

The following forms are for your reference only:


Notice of Privacy Practices

Endodontic Post Treatment Instructions