AV Dental Ramsey New Registration Form

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To My Appreciated Patient.* This field is required.This year marks the beginning of many exciting changes in my office in my effort to improve service and quality of care for you so that you can regain and maintain your health as quickly, efficiently, and inexpensively as possible. I have a purpose - and that purpose is to get sick people well and to prevent the well from getting sick. I also have a personal, professional, and ethical responsibility to care for your health to the best of my ability. Missed appointments and failure to comply with recommended treatment schedules and/or procedures prevent me from achieving my goal of optimum health for you. If you cannot keep your appointments and adhere to my treatment recommendations, I will not be able to continue treating you in good conscience. Therefore, the following policies must be agreed upon: 1. No-shows are not acceptable. Failure to make an appointment not only compromises your health but inconveniences other patients who may have requested an office visit during your scheduled appointment. If you cannot make an appointment (except in the case of an emergency) you are expected to call within 48 hours of your appointment to reschedule. There is a $50.00 fee for all no-show appointments per hour and this fee is not covered by insurance. This money will be matched by CLIENT NAME and donated to St. Jude’s Children’s Hospital. 2. Timeliness is required. We will see you on time and get you out on time unless there is an emergency. We request that you be on time for your visits. If you are more than 10 minutes late, you may have to reschedule your appointment. 3. Cleanliness and infection control are of the utmost importance. We have the - latest sterilization technology and disinfect each treatment room after every patient. This is another important reason we demand timeliness of you and ourselves. We request that you brush your teeth prior to being seated in a treatment room. Toothbrushes, paste, mouth rinse, and floss will be provided for you if needed. 4. If you miss an appointment you must make it up. It is critical to your health to do so to avoid setbacks in the care and maintenance of your teeth and gums. 5. Insurance: Treatment recommendations are based on your health not on your insurance or lack thereof. If you have insurance it is your responsibility to be aware of what your benefits are. Remember insurance companies are not concerned about your health or well being - we are. We will provide you with an estimate of benefits; however you are fully responsible for any treatment performed. Your benefits are a contract between you and your insurance company. We cannot be responsible for what your insurance will or will not cover. 6. We run a Zero Balance office. We expect payment in full prior to or at the time treatment is provided. We have several financial options available for all of our patients. Please speak to (designated team member) if you have any questions. 7. In order to schedule an appointment with DR. Arash Vahid, we require 50% of the total patient out-of-pocket expense as a deposit and a signed financial agreement. 8. Our policy is to make your experience in our office an exceptional one. When we succeed, we would appreciate you telling your family and friends about our office. 9. Upsets: It is our company policy to ensure the complete satisfaction of all of our patients with the service and care they receive at our office. However, it is possible on occasion that there may be a misunderstanding or miscommunication between you and our office. We will do everything in our power to make things right by you should an upset occur provided you bring it to our attention in an appropriate, cordial manner and at a time that we can give the matter the proper attention it deserves for effective resolution. You can expect that my staff will treat you with the same professional demeanor and efficiency, as you would expect from them. Pl·ease see our office manager to resolve immediately any upsets you may have with my office or one of my team. 10. Emergencies: It is our goal to eliminate all of the potential dental emergencies you may have by providing care for you before it becomes a problem. In the rare instance that you do have an emergency we want you to be assured that we will take care of you. In order to do this we would like to define what a true emergency is. Swelling, bleeding, severe pain that has kept you up at night or requires medication, or a restoration in a visible area that falls out are all considered emergencies. If you have any of these symptoms we ask that you call us right away. We will provide you with the next available emergency appointment. We do set aside time each day for emergencies. I greatly appreciate your cooperation. Yours in Health, Dr. Arash Vahid
First Name
Last Name
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Patient Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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Phone Number* This field is required.
Area Code
Phone Number
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Personal Information* This field is required.
Street Address, City, State, Zip Code
Email
Please Select
Please Select
Male
Female
Gender
Age
Birthdate
Select Marital Status
Select Marital Status
Married
Widowed
Single
Minor
Separated
Divorced
Marital Status
Patient Employer/School
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Referral Source* This field is required.Please let us know how you referred to our business. For example; friend's name, Google, Facebook, etc. If none, please type in none.
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Insurance Information* This field is required.
Who is responsible for this account?
Relationship to Patient
Insurance Company
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Assignment & Release Signature* This field is required.I certify that I, and/or my dependent(s) have insurance coverage and assign directly to Dr. Arash Vahid all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
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Emergency Contact Information* This field is required.IN CASE OF EMERGENCY CONTACT (Specify someone who doesn’t live in your household)
Name
Relationship
Phone Number
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Check the symptoms that apply to you:* This field is required.If none, please select none and click next.
NONE
Bad Breath
Bleeding Gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of the mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to hearing
Sensitivity to sweets
Sensitivity when biting
Sores or growths in the mouth
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How often do you floss per day?* This field is required.
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How often do you brush per day?* This field is required.
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Have your ever taken any of the groups of drugs collectively referred to as “fen-phen?”* This field is required.These include combinations of lonimin, Apidex, Fastin,(brand names of phentermine), Pondimin (lenfluramine) and Redux(dexfenluramine).
Yes
No
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Check the conditions that apply to you:* This field is required.If none of the conditions apply, please select NONE.
NONE
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally with extractions or surgery
Blood pressure
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or Growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained
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Medical History Signature* This field is required.
Clear
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What are you looking for in a dentist?
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Would you like whiter teeth?
YESNO
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Please check the boxes that best describe you to help us make your visit more pleasant:
I require detailed explanation about my dental treatment and insurance coverage
Weekend and evening appointments are important to me
Timeliness is important to me. Please try to make my waiting time as minimal as possible.
Insurance participation is very important to me
I dont like the sound of dental tools/drill
I dont like needles
I gag easily
I don't like cotton in my mouth
I had a previous bad experience at the dentist
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Type of Hepatitis* This field is required.
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Women's Questions* This field is required.
Please Select
Please Select
Yes
No
Are you pregnant?
Please Select
Please Select
Yes
No
Are you on birth control?
Due Date for Pregnancy
Please Select
Please Select
Yes
No
Are you nursing?
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List any medications you are currently taking and the correlating diagnosis.* This field is required.If none, please type in none.
Huge
Large
Normal
Small
Ok
Ok
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Medications Signature* This field is required.
Clear
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Allergies* This field is required.If none, please select none.
Aspirin
Barbiturates (Sleeping Pills)
Iodine
Latex
Local Anaesthetic
Penicillin
None
Other
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Allergies Signature* This field is required.
Clear
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Dentist SignatureDr. Arash Vahid
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Patient Signature* This field is required.
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Patient Acknowledgments of Receipt of Privacy Practices NoticePlease click Next to Agree
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Patient or Personal Representative Information* This field is required.
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Patient or Personal Representative Signature* This field is required.
Clear
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