What to Bring:
- List of current medication, if applicable
- Dental insurance card, if applicable
- Previous X-rays and records or fax Authorization of Release of Information form from previous dental provider
- Please print and fill out the following forms:
- Welcome Adult Health History
- Authorization to Release Health Information*
- *This form is to be sent to previous dental offices for records and X-rays. For this form, please add to the Please Forward/release my health information to:
Dr. Ellis K. List
1020 Broad St.
Durham, NC 27705
- Consent for Treatment
- Consent for Use and Disclosure of Health Information
- Directions to Our Office
- Notice of Privacy Practices (read-only)
- Smile Analysis
- TMJ Pain Questionnaire
- Acknowledgment of Receipt of Notice of Privacy Practices
What to Expect:
We will treat you with respect. To determine the cause of your emergency, a limited examination and appropriate X-rays of the suspected area will be done to diagnose the problem and assess the extent of the damage to the tooth or gum. We will answer all of your questions and discuss options for treatment. Relieving your immediate discomfort is our goal, with your permission. We will help you understand your insurance coverage. Payment is expected at the time of service, in full or estimate of insurance co-pay.
If you are experiencing a dental emergency in Durham, North Carolina, please call the office of Ellis K. List, DDS, PA at 919-682-5327 as soon as possible. Our dentist and dental team are dedicated to caring for you when you need it!