New Patient Registration and consent form
16TEETH
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16TEETH
Clinic Name:
Black Diamond Dental Clinic L.L.CTrade License No. 773574 – Dubai Media City – Office No. 2707, Al Sufouh 2Licensed by the Dubai Department of Economy & Tourism Website: www.16Teeth.com Phone: +971 50 940 2323 | Email: management@16Teeth.com
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Permission.
Permission to share my health information through the Health Information Exchange System (NABIDH) in accordance with the United Arab Emirates legislation and Dubai Health Authority,and medical and dental authorities all over the world.General Treatment Consent: I consent to receive dental and/or medical care at this facility.NABIDH / Data Sharing Consent: I authorize my health data to be securely shared with DHA through the Health Information Exchange System (NABIDH).Photography / Marketing Consent: I consent to before-and-after photos being taken for documentation. I consent for photos to be used anonymously for educational/marketing purposes.Financial Consent: I agree to pay all fees not covered by my insurance.
🏛️ COMPANY PROFILE
Company Name: Black Diamond Dental Clinic L.L.C Trade License No.: 773574 Registered Address: Office No. 2707 – Al Sufouh 2 – Dubai Media City – Dubai – United Arab Emirates Licensed by: Dubai Department of Economy & Tourism (DET) Website: www.16Teeth.com Email: management@16Teeth.com Phone: +971 50 940 2323 | +971 56 714 0443 ⸻ About the Company Black Diamond Dental Clinic L.L.C is an officially licensed medical and dental facility operating under the brand 16Teeth, founded and supervised by Dr. Mostafa Osama, an internationally recognized expert in modern cosmetic and non-shaving dental technologies. The clinic is part of the 16Teeth Global Network, which operates across the UAE, Egypt, and the United States, offering premium dental and aesthetic services through licensed clinics managed under a unified quality and ethical system. ⸻ Our Mission To deliver world-class dental and cosmetic treatments built on trust, technology, and transparency — ensuring every patient experiences high-quality, ethical, and personalized care within a luxurious environment. ⸻ Our Vision To become the leading global dental brand representing innovation, precision, and integrity — transforming smiles and lives while maintaining excellence and trust as the foundation of every treatment. ⸻ Our Core Values • Professional Integrity: All treatments are based on clinical need and ethical standards. • Innovation: We use cutting-edge technologies and materials sourced from global leaders like Ivoclar Vivadent and Straumann. • Transparency: Clear pricing, full documentation, and honest consultation for every patient. • Excellence: A team of certified dentists and specialists under continuous supervision. • Patient Trust: Every decision prioritizes the patient’s health, safety, and satisfaction. ⸻ Our Services 🦷 Non-shaving & Ceramic Veneers 🦷 Braces & Aligners (ceramic / invisible) 🦷 Dental Implants (single or full-mouth) 🦷 Fillings & Restorations 🦷 Whitening, Cleaning & Polishing 🦷 Cosmetic Smile Makeovers 🦷 General Dentistry & Emergency Visits ⸻ Our Signature Plan 16Teeth Royal Dental Insurance – Dubai’s first real dental and cosmetic coverage plan offering unlimited treatments including veneers, braces, implants, and fillings under one annual fee. This exclusive membership ensures priority access, 24/7 support, and professional supervision at Black Diamond Dental Clinic LLC — licensed in Dubai Media City.
💎 16TEETH DENTAL INSURANCE PLANS (2025)
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Please Select
🥇 1. SILVER PLAN – Essential Care (1,990 AED / Year)
🥈 2. GOLD PLAN – Advanced Cosmetic & Medical Care (3,490 AED / Year)
👑 3. ROYAL PLAN – Full Unlimited Coverage (4,990 AED / Year)
Payment must be made at the clinic after signing this agreement and receiving a stamped copy for your records.
Patient’s Name :
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Full Phone Number:
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Make sure all entries follow this format: 971507577500/201011111485. This ensures accurate and consistent search results.
Phone Number (without last three digits)
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Make sure all entries follow this format: 971507577500/201011111485. This ensures accurate and consistent search results.
Patient’s Email:
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example@example.com
Date of Birth
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Month
Year
Date
Gender
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male
female
Nationality
ID Number
Marital Status
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Single
Married
Other
Residential Address
Emergency Contact Number
Existing Medical Conditions
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1. Diabetes (Sugar Disease)
2. Hypertension (High Blood Pressure)
3. Hypotension (Low Blood Pressure)
4. Heart Disease
5. Asthma
6. Thyroid Disorder (Hyperthyroidism / Hypothyroidism)
7. Liver Disease / Hepatitis
8. Kidney Disease
9. Epilepsy / Seizures
10. Bleeding Disorders (Hemophilia / Easy Bruising)
11. Blood Disorders (Anemia, Thalassemia, etc.)
12. Stroke / Paralysis History
13. Cancer
14. Respiratory Problems (COPD / Chronic Cough)
15. Tuberculosis (TB)
16. HIV / AIDS
17. Gastric Ulcer or Acid Reflux
18. Arthritis / Joint Pain
19. Osteoporosis
20. Psychological or Anxiety Disorders
21. Depression
22. Allergy (Drug / Food / Latex)
23. Autoimmune Diseases (e.g., Lupus, Rheumatoid Arthritis)
24. Pregnancy / Breastfeeding
25. Chronic Pain or Migraine
26. Neurological Disorders (Parkinson’s, Multiple Sclerosis)
27. Sleep Apnea
28. Smoking / Tobacco Use
29. Alcohol Use
30. None
Others (please specify)
Others (please specify)
Current Medications
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1. Blood Pressure Medication (e.g., Amlodipine, Losartan, Captopril)
2. Diabetes Medication (e.g., Metformin, Insulin, Glimepiride)
3. Thyroid Medication (e.g., Eltroxin, Thyroxine)
4. Cholesterol Medication (e.g., Atorvastatin, Rosuvastatin)
5. Heart Medication (e.g., Nitroglycerin, Digoxin, Bisoprolol)
6. Blood Thinners (e.g., Aspirin, Warfarin, Clopidogrel)
7. Antibiotics (e.g., Amoxicillin, Augmentin, Azithromycin)
8. Painkillers (e.g., Paracetamol, Ibuprofen, Diclofenac, Tramadol)
9. Anti-Inflammatory Drugs (e.g., Prednisone, Cortisone)
10. Anti-Allergy Medication (e.g., Cetirizine, Loratadine)
11. Antidepressants (e.g., Sertraline, Fluoxetine)
12. Anti-Anxiety Medication (e.g., Alprazolam, Diazepam)
13. Inhalers (e.g., Ventolin, Seretide, Symbicort)
14. Gastric Medication (e.g., Nexium, Omeprazole, Gaviscon)
15. Iron or Vitamin Supplements (e.g., Ferrosanol, Vitamin D, B-Complex)
16. Oral Contraceptive Pills
17. Hormonal Therapy
18. Anti-Epileptic Medication (e.g., Carbamazepine, Valproate)
19. Anti-Cancer Medication (Chemotherapy)
20. Immunosuppressants (e.g., Methotrexate, Cyclosporine)
21. Asthma Medication
22. Sleeping Pills (e.g., Zolpidem)
23. Herbal or Homeopathic Remedies
24. None
Other – Please Specify:
Current Medications Other – Please Specify:
Allergies-Past Surgeries or Hospitalizations -Are You Pregnant or Breastfeeding
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Main Reason for Purchasing the Plan
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Please Select
1. Routine dental check-up and cleaning
2. Tooth pain or sensitivity
3. Tooth decay or cavity treatment (fillings)
4. Cracked or broken tooth repair
5. Root canal treatment
6. Tooth extraction or wisdom tooth removal
7. Gum problems (bleeding, swelling, gingivitis, periodontitis)
8. Deep cleaning / scaling and polishing
9. Bad breath (halitosis) treatment
10. Fluoride treatment or preventive sealants
11. Teeth whitening
12. Composite veneers / bonding
13. Porcelain or non-shaving veneers
14. Smile makeover consultation
15. Hollywood smile design
16. Digital smile simulation
17. Gum contouring or reshaping
18. Enamel reshaping or repair
19. Tooth jewelry application
20. Orthodontic braces (metal, ceramic, or self-ligating)
21. Invisible aligners (clear aligners)
22. Retainer fitting or replacement
23. Bite correction (overbite, underbite, crossbite)
24. Orthodontic emergencies (loose bracket or wire)
25. Dental implants (single or full mouth)
26. Sinus lift procedure
27. Bone grafting
28. Surgical tooth extraction
29. Implant crown or bridge placement
30. Crown or bridge replacement
31. Veneer replacement
32. Full or partial denture fabrication
33. Onlay / inlay restoration
34. Bite adjustment
35. Pediatric dental check-up and cleaning
36. Milk tooth extraction
37. Dental sealants for children
38. Fluoride varnish application
39. Space maintainers
40. Habit-breaking appliance (thumb sucking, mouth breathing)
41. TMJ (jaw joint) pain or clicking
42. Cyst or tumor removal
43. Jaw alignment or corrective surgery
44. Facial trauma management
45. Gum pocket reduction
46. Laser gum therapy
47. Bone regeneration treatment
48. Retreatment of failed root canal
49. Post & core placement
50. Botox for smile line or gummy smile correction
51. Lip fillers for smile balance
52. PRF / PRP for gum and skin rejuvenation
53. Laser facial esthetic treatment
54. Aesthetic consultation for full-face enhancement
55. Post-treatment follow-up or maintenance visit
Where You Found Us :
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Please Select
• Instagram / Facebook ad
• Google or website
• Referral or walk-in
patient occupation
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1. Dentist
2. Lawyer
3. Celebrity
4. Housewife
5. Government Employee
6. Business Owner
7.Other
Payment Options:
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Cash
Foreign Currency Cash
16TEETH - Debit Card (Visa / Mastercard)
CLINIC - Debit Card (Visa / Mastercard)
Prepaid / Gift Card
Insurance Card
Stripe
PayTabs
PayFort
Telr
Local Bank Transfer (IBAN)
International Bank Transfer (SWIFT)
Tamara
Tabby
Spotii
Postpay
Cheque Payment
instapay
Amount Paid / المبلغ المدفوع:
Please Select
1,990 AED
3,490 AED
4,990 AED
Payment must be made at the clinic after signing this agreement and receiving a stamped copy for your records.
ID or Driver liscence or passport(FRONT PAGE )
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ID or Driver liscence or passport( BACK PAGE)
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Comprehensive Consent Form for Media Use and Advertising
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No
Comprehensive Consent Form for Media Use and Advertising
Comprehensive Consent Form for Media Use and Advertising By signing below, I hereby grant Dr. Mostafa Osama Mahmoud, Dr. Mostafa Osama’s Sixteen Teeth, and their affiliated businesses irrevocable, perpetual, worldwide rights to use, reproduce, edit, and distribute my videos and photos for any marketing, advertising, or promotional purposes. This includes, but is not limited to: • Posting on social media platforms (e.g., Instagram, Facebook, TikTok, YouTube). • Displaying on digital or physical screens, billboards, or any other advertising medium. • Use in promotional materials, brochures, or online advertisements related to the business. Acknowledgments and Terms 1. I confirm that I have reviewed and approved the videos and photos before providing my consent. 2. I waive any right to inspect or approve the final product where my likeness appears, including written or electronic copy. 3. I understand that this consent is irrevocable and unlimited in duration and applies to all current and future businesses owned or affiliated with Dr. Mostafa Osama Mahmoud and Dr. Mostafa Osama’s Sixteen Teeth. 4. I acknowledge that this consent grants usage rights without any financial compensation to me, now or in the future. 5. I waive any claims of ownership, royalties, or other compensation regarding the use of my likeness in these materials. 6. I release Dr. Mostafa Osama Mahmoud, Dr. Mostafa Osama’s Sixteen Teeth, and their affiliated businesses from any liability related to the use of my videos or photos, including claims of defamation, invasion of privacy, or violation of rights of publicity. 7. I confirm that the media may be altered, edited, or combined with other content as deemed appropriate for the purposes outlined. Non-Revocation Clause • I understand that my consent is permanent and cannot be revoked once given. Legal and Dispute Resolution • This agreement is governed by the laws of the jurisdiction in which Dr. Mostafa Osama’s Sixteen Teeth operates. • Any disputes arising from this consent will be resolved exclusively through arbitration in the business’s jurisdiction.
🥇 1. SILVER PLAN – Essential Care
🥇 1. SILVER PLAN – Essential Care Price: 1,990 AED / year Ideal for: Basic maintenance & prevention Includes: ✅ 4 dental cleanings per year ✅ 2 checkups with X-rays ✅ 5 tooth filling (any type) ✅ 2 whitening session ✅ 50% discount on veneers, braces, and implants ✅ Free emergency visits & priority booking Benefits: • Affordable protection for essential dental health • Access to all 16Teeth licensed clinics • Perfect for individuals or small company employees
🥈 2. GOLD PLAN – Advanced Cosmetic & Medical Care
🥈 2. GOLD PLAN – Advanced Cosmetic & Medical Care Price: 3,490 AED / year Ideal for: Patients needing medical + cosmetic coverage Includes: ✅ 6 cleanings & checkups per year ✅ Free X-rays anytime ✅ 10 tooth fillings ✅ 4 whitening sessions ✅ 75% discount on veneers, braces, and implants ✅ 4 free consultation with cosmetic specialist ✅ Emergency & follow-up visits included Benefits: • Combines dental treatment with cosmetic upgrades • Professional supervision by 16Teeth team • Great for families or professionals maintaining active dental care
👑 3. ROYAL PLAN – Full Unlimited Coverage
👑 3. ROYAL PLAN – Full Unlimited Coverage Price: 4,990 AED / year Ideal for: Complete cosmetic, medical & luxury care Includes: ✅ Unlimited visits, checkups, and consultations ✅ Unlimited cleanings, whitening, and X-rays ✅ Unlimited veneers (non-shaving ) ✅ Unlimited braces & aligners ✅ Unlimited dental implants ✅ Unlimited fillings & restorations ✅ 24/7 VIP support & priority booking ✅ Full treatment under 16Teeth licensed clinics (Dubai & Egypt) Benefits: • No limits, no hidden terms • All services under one plan • Real coverage from licensed clinic, not a third-party insurance • The ultimate plan for those who want perfection
Data Privacy and Confidentiality Consent
Data Privacy and Confidentiality Consent I understand that my personal, medical, and dental information is collected solely for the purpose of diagnosis, treatment, and record management within the clinic. I acknowledge that my data will be stored securely and accessed only by authorized clinical staff for professional use. My information will not be shared with any third party without my written consent, except when required by law, insurance purposes, or professional regulations. I consent to the collection, use, and secure storage of my personal and medical data in accordance with applicable privacy laws and ethical standards. By signing below, I confirm that I have read and understood this policy and agree to the proper handling of my personal information as stated above.
TERMS AND CONDITIONS - 16Teeth Silver Dental Insurance Plan
TERMS AND CONDITIONS 16Teeth Silver Dental Insurance Plan Black Diamond Dental Clinic L.L.C – Trade License No. 773574 Location: Office No. 2707, Al Sufouh 2, Dubai Media City, UAE Website: www.16Teeth.com Phone: +971 50 940 2323 | Email: management@16Teeth.com ⸻ 1. Definition • “Company” or “Clinic” refers to Black Diamond Dental Clinic L.L.C, operating under the brand 16Teeth. • “Client” or “Member” refers to the patient subscribing to the 16Teeth Silver Dental Insurance Plan. • “Dentist” refers to the licensed practitioner providing diagnosis and treatment on behalf of the Clinic. ⸻ 2. Nature of the Plan • The 16Teeth Silver Dental Insurance Plan is a membership-based coverage designed for patients seeking essential and preventive dental care at a fixed annual fee. • It is not a third-party or government insurance program; all treatments are provided directly by the Clinic. ⸻ 3. Diagnostic and Treatment Authority • All diagnoses, treatments, and medical decisions are made solely by the Clinic’s licensed dentists, based on professional assessment and medical necessity. • The patient acknowledges that treatment requests (e.g., veneers, braces, implants) may be approved, modified, or declined at the dentist’s discretion for ethical, medical, or safety reasons. • The Clinic reserves the exclusive right to determine what treatment is suitable and clinically indicated. • The patient waives any right to demand a specific treatment against professional opinion. ⸻ 4. Coverage and Limitations The Silver Plan includes but is not limited to: ✅ 4 dental cleanings per year ✅ 2 checkups with X-rays ✅ 5 tooth fillings (any type) ✅ 2 whitening sessions per year ✅ 50% discount on veneers, braces, and implants ✅ Free emergency visits and priority booking Benefits: • Affordable protection for essential dental health • Access to all 16Teeth licensed clinics • Ideal for individuals or small company employees ⸻ Limitations: • All services must be performed within 16Teeth licensed clinics only. • The plan is valid for 12 months from activation and is non-transferable. • The plan does not cover: • Treatments or procedures performed outside the clinic • Damages from accidents, negligence, or non-compliance • Work corrected or altered by another dentist or clinic • Refunds or replacements for dissatisfaction unrelated to medical fault ⸻ 5. Fees and Refunds • The annual fee is 1,990 AED, payable in full before plan activation. • Payments are non-refundable once activated, regardless of service usage. • No partial refunds or extensions will be granted for missed appointments or delayed treatments. ⸻ 6. Appointments and Conduct • All appointments must be scheduled through official 16Teeth contact channels. • A minimum of 24 hours’ notice is required for cancellations or rescheduling. • Repeated cancellations or no-shows may result in plan suspension. • Disrespectful behavior, misconduct, or verbal abuse toward staff will result in immediate termination of the plan without refund. ⸻ 7. Medical Disclaimer • Dental results vary based on individual oral conditions, habits, and hygiene. • The Clinic does not guarantee identical outcomes to other patients or marketing images. • The Clinic shall not be held liable for complications caused by pre-existing conditions, smoking, or patient negligence. ⸻ 8. Confidentiality • All patient records and data are confidential and protected under UAE privacy laws. • The Clinic may use anonymized before/after photos for educational or marketing purposes only with the patient’s written consent. ⸻ 9. Indemnity • The Client agrees to indemnify and hold harmless Black Diamond Dental Clinic L.L.C and its staff from any claims, losses, or damages resulting from misuse of the plan, false declarations, or failure to follow clinical advice. ⸻ 10. Governing Law and Jurisdiction • This agreement shall be governed by and construed in accordance with the laws of the United Arab Emirates. • Any disputes shall be subject to the exclusive jurisdiction of the Dubai Courts. ⸻ 11. Acceptance By signing or activating this plan, the Client confirms: • That they have read, understood, and accepted these Terms and Conditions in full. • That they agree to follow the dentist’s professional opinion and respect clinical authority. • That they release the Clinic from liability related to self-demanded or medically unjustified procedures.
TERMS AND CONDITIONS - 16Teeth Gold Dental Insurance Plan
TERMS AND CONDITIONS 16Teeth Gold Dental Insurance Plan Black Diamond Dental Clinic L.L.C – Trade License No. 773574 Location: Office No. 2707, Al Sufouh 2, Dubai Media City, UAE Website: www.16Teeth.com Phone: +971 50 940 2323 | Email: management@16Teeth.com ⸻ 1. Definition • “Company” or “Clinic” refers to Black Diamond Dental Clinic L.L.C, operating under the brand 16Teeth. • “Client” or “Member” refers to the patient subscribing to the 16Teeth Gold Dental Insurance Plan. • “Dentist” refers to the licensed practitioner providing diagnosis and treatment on behalf of the Clinic. ⸻ 2. Nature of the Plan • The 16Teeth Gold Dental Insurance Plan is a membership-based program designed for patients seeking both medical and cosmetic dental treatments with extended coverage at a fixed annual fee. • It is not a third-party or government insurance; all treatments are provided directly by Black Diamond Dental Clinic L.L.C. ⸻ 3. Diagnostic and Treatment Authority • All diagnoses, treatments, and medical decisions are made solely by the Clinic’s licensed dentists, based on clinical findings. • The patient acknowledges that treatment requests (e.g., veneers, implants, braces) may be approved, modified, or declined at the dentist’s discretion for medical, ethical, or safety reasons. • The Clinic retains full professional authority to decide the appropriate treatment plan. • The patient waives any right to demand a specific procedure against professional opinion. ⸻ 4. Coverage and Limitations The Gold Plan includes but is not limited to: ✅ 6 cleanings & checkups per year ✅ Free X-rays anytime ✅ 10 tooth fillings ✅ 4 whitening sessions per year ✅ 75% discount on veneers, braces, and implants ✅ 4 free consultations with a cosmetic specialist ✅ Emergency & follow-up visits included Benefits: • Combines medical care with premium cosmetic coverage • Supervised by the 16Teeth professional team • Ideal for families and professionals who maintain active dental care ⸻ Limitations: • All services must be performed within 16Teeth licensed clinics. • The plan is valid for 12 months from activation and is non-transferable. • The plan does not cover: • Treatments or procedures performed outside the clinic • Damages from accidents, negligence, or non-compliance • Work redone or altered by another dentist or clinic • Refunds or replacements for dissatisfaction unrelated to medical fault ⸻ 5. Fees and Refunds • The annual fee is 3,490 AED, payable in full before activation. • Payments are non-refundable once activated, regardless of usage. • No partial refunds or extensions will be granted for missed appointments or unused benefits. ⸻ 6. Appointments and Conduct • Appointments must be booked in advance through official 16Teeth contact channels. • A minimum of 24 hours’ notice is required for cancellations or rescheduling. • Repeated cancellations or failure to attend appointments may lead to temporary suspension of the plan. • Disrespectful or inappropriate behavior toward staff will result in immediate plan termination without refund. ⸻ 7. Medical Disclaimer • Dental results vary depending on oral condition, hygiene habits, and patient cooperation. • The Clinic does not guarantee identical results to other patients or marketing visuals. • The Clinic is not liable for complications due to pre-existing conditions, smoking, or patient neglect. ⸻ 8. Confidentiality • All patient information and records are confidential under UAE data protection laws. • The Clinic may use anonymized before/after photos for educational or marketing purposes only with written patient consent. ⸻ 9. Indemnity • The Client agrees to indemnify and hold harmless Black Diamond Dental Clinic L.L.C and its staff from any claims, losses, or damages resulting from misuse of the plan, false declarations, or failure to comply with medical instructions. ⸻ 10. Governing Law and Jurisdiction • This agreement is governed by the laws of the United Arab Emirates. • Any disputes arising hereunder shall be resolved under the exclusive jurisdiction of the Dubai Courts. ⸻ 11. Acceptance By signing or activating this plan, the Client confirms: • That they have read, understood, and accepted these Terms and Conditions in full. • That they agree to follow the dentist’s professional opinion and respect the clinic’s medical authority. • That they release the Clinic from any liability related to self-demanded or non-medically indicated treatments.
TERMS AND CONDITIONS - 16Teeth Royal Dental Insurance
16Teeth Royal Dental Insurance Black Diamond Dental Clinic L.L.C – Trade License No. 773574 Location: Office No. 2707, Al Sufouh 2, Dubai Media City, UAE Website: www.16Teeth.com Phone: +971 50 940 2323 | Email: management@16Teeth.com ⸻ 1. Definition • “Company” or “Clinic” refers to Black Diamond Dental Clinic L.L.C, operating under the brand 16Teeth. • “Client” or “Member” refers to the patient subscribing to the 16Teeth Royal Dental Insurance Plan. • “Dentist” refers to the licensed practitioner providing diagnosis and treatment on behalf of the Clinic. ⸻ 2. Nature of the Plan • The 16Teeth Royal Dental Insurance Plan is a membership-based coverage that allows clients to access a range of dental and cosmetic treatments for a fixed annual fee. • It is not a third-party or government insurance program; all treatments are provided directly by the Clinic. ⸻ 3. Diagnostic and Treatment Authority • All diagnoses, treatments, and medical decisions are made solely by the Clinic’s licensed dentists, based on clinical findings. • The patient acknowledges that treatment requests (e.g., veneers, implants, braces) may be approved, modified, or declined at the dentist’s discretion for medical, ethical, or safety reasons. • The Clinic holds the exclusive right to determine what treatment is suitable and medically indicated. • The patient waives any right to demand a specific procedure against professional opinion. ⸻ 4. Coverage and Limitations The plan includes but is not limited to: ✅ Veneers (non-shaving) ✅ Braces and Aligners (ceramic/invisible) ✅ Dental Implants (single units only) ✅ Fillings and Restorations ✅ Whitening, Cleaning, and Polishing ✅ Consultations, X-rays, and Emergency Visits Limitations: • All services must be performed within 16Teeth licensed clinics. • The plan is valid for 12 months from activation and is non-transferable. • The plan does not cover: • Procedures performed outside the clinic • Damages from accidents, negligence, or non-compliance • Work altered by another dentist or clinic • Refunds or replacements for dissatisfaction unrelated to medical fault ⸻ 5. Fees and Refunds • The annual fee (4,990 AED or other selected plan value) is payable in full before activation. • Payments are non-refundable once the plan is activated, regardless of usage. • No partial refunds or extensions will be granted for missed appointments or delayed treatments. ⸻ 6. Appointments and Conduct • All appointments must be pre-booked through the official contact channels. • A minimum of 24 hours’ notice is required for cancellations or rescheduling. • Repeated cancellations or no-shows may result in suspension of plan privileges. • Disrespectful behavior, misconduct, or verbal abuse toward staff may lead to immediate plan termination without refund. ⸻ 7. Medical Disclaimer • Dental and cosmetic results vary depending on individual health, habits, and oral condition. • The Clinic does not guarantee identical results to marketing images or other patients. • The Clinic shall not be liable for complications caused by pre-existing conditions, smoking, or patient neglect. ⸻ 8. Confidentiality • All patient data and medical records are confidential and protected under UAE data privacy laws. • The Clinic may use anonymized before/after photos for educational or promotional purposes only with the patient’s written consent. ⸻ 9. Indemnity • The Client agrees to indemnify and hold harmless Black Diamond Dental Clinic L.L.C and its staff from any claims, costs, or damages arising from misuse of the plan, false declarations, or non-compliance with clinical advice. ⸻ 10. Governing Law and Jurisdiction • This agreement shall be governed by and construed in accordance with the laws of the United Arab Emirates. • Any dispute shall fall under the exclusive jurisdiction of the Dubai Courts. ⸻ 11. Acceptance By signing or activating the plan, the Client confirms: • That they have read, understood, and accepted these Terms and Conditions in full. • That they agree to follow the dentist’s medical opinion and respect the clinic’s professional authority. • That they release the Clinic from liability related to self-demanded or medically unjustified procedures.
Black Diamond Dental Clinic L.L.C — Official Treatment Price List
💎 BLACK DIAMOND DENTAL CLINIC L.L.C Luxury Cosmetic & Dental Care by 16Teeth 📍 Office 2707, Al Sufouh 2, Dubai Media City 🌐 www.16Teeth.com | 📞 +971 50 940 2323 | ✉️ management@16Teeth.com ⸻ 🦷 COSMETIC DENTISTRY • Non-shaving veneers (per tooth): 1,250 – 1,950 AED • Porcelain veneers (per tooth): 2,200 – 2,800 AED • Smile makeover (16 teeth): 19,900 – 29,000 AED • Hollywood smile (full mouth): 35,000 – 45,000 AED • Tooth whitening (in-clinic): 1,500 – 2,200 AED • Whitening package (2 sessions): 3,000 – 3,500 AED ⸻ 🪄 ORTHODONTICS • Ceramic braces (full case): 10,000 – 14,000 AED • Metal braces (full case): 8,500 – 10,500 AED • Invisible aligners (per arch): 9,500 – 13,000 AED • Retainers (per arch): 1,200 – 1,800 AED ⸻ 🦷 DENTAL IMPLANTS • Single implant (implant + crown): 4,900 – 7,500 AED • All-on-4 implant system (per arch): 29,000 – 39,000 AED • All-on-6 implant system (per arch): 35,000 – 49,000 AED • Bone graft / sinus lift (if required): 3,500 – 6,000 AED ⸻ 🪥 GENERAL & RESTORATIVE CARE • Consultation + check-up (with X-ray): 350 AED • Digital smile design (3D preview): 850 – 1,200 AED • Tooth filling (composite): 450 – 850 AED • Root canal treatment (per tooth): 1,500 – 2,500 AED • Cleaning + polishing: 500 – 850 AED • Scaling + stain removal + fluoride: 750 – 1,200 AED ⸻ 🪷 AESTHETIC & ADDITIONAL SERVICES • Gum contouring / reshaping: 1,500 – 2,200 AED • Tooth jewelry (crystal / gold): 700 – 1,500 AED • Night guard / retainer: 1,000 – 1,800 AED • Emergency dental visit: 550 – 850 AED • Cosmetic consultation / mock-up: 500 – 700 AED ⸻ 💎 16TEETH PREMIUM PLANS • 🥇 Silver Plan – Essential Care: 1,990 AED / year • 🥈 Gold Plan – Advanced Cosmetic & Medical: 3,490 AED / year • 👑 Royal Plan – Full Unlimited Coverage: 4,990 AED / year ⸻ Notes • All services performed by licensed dentists in Dubai Media City. • Prices depend on case complexity & chosen materials. • Full cost estimate provided after clinical evaluation. • Payments are non-refundable once treatment begins.
CLIENT'S Signature
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