New Patient Registration

Please correct the errors described below.

Patient Information

Patient


* If child, provide parent/guardian name(s)


** If student, please complete:

Please check preferred contact phone:

Emergency Information

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient's address:

Employment Information

Insurance Information

Subscriber

Previous Dentist

Dental History

Primary Physician Information

Medical History

Female Patients

All Patients: Do you have, or have you ever had any of the following? (Check all that apply):

All Patients: Are you allergic to or have you ever had any reaction to the following (check all that apply):

All Patients: Are you currently taking any of the following (check all that apply):

Add Drug Name

I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Information Release

Patient Contact Preferences

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

By signing below, I acknowledge that I have read and understand the ALL statements mentioned in this new patient packet.

Agreement to Receive Electronic Communication

I agree that the dental practice may communicate with me electronically at the email address below.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

I am responsible for providing the dental practice any updates to my email address.

I can withdraw my consent to electronic communications by calling the office at 281-859-9073.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Acknowledgement of Receipt of Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgement*

I have received a copy of this office's Notice of Privacy Practices.

By signing this form, you will consent to our and disclosure of you protected health information as detailed in our Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Financial Guidelines

We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines.

Insurance

  • Dental insurance can be confusing and is often misunderstood. We would like to take this time to clear up some common misconceptions.
  • We do not base our recommended treatment on what your dental insurance will or will not pay. We will, however make every effort to assist you with maximizing your dental benefits.
  • As courtesy, we will prepare and submit your dental claims. We will provide estimates of expected dental benefits, based on the information provided to us by your dental insurance. The estimated patient portion of each visit is due at the time of treatment.
  • Insurance estimates are based on the limited amount of information provided to us by your insurance company, if your insurance pays more that estimated, any overpayment will be refunded to you immediately. If you choose, we will the credit on your account for any future dental treatment. If your insurance pays less that estimated, you are solely responsible for any balance left on your account.
  • Dr.Al (Ali Alkhiro DDS) will accept assignment of benefits for services rendered.
  • If you have any further questions pertaining to dental insurance, please feel free to talk with our front desk staff.

Payments

  • Patient portion or patient co-pay is due at the time services are rendered - unless prior financial arrangement have been made.
  • Payment Information:
    • Credit cards accepted: Visa, MasterCard, Discover, and American Express
    • Various financing options with CareCredit
  • Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service.

Appointment Policy

  • Please give 48 hours (2 working days) notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments, and we appreciate the same courtesy from you. If a patients more than 10 minutes late for their reserved time, we may need to reschedule their appointment.
  • Short canceled or missed appointments will be charged $70 per appointment.

ABOUT YOUR DENTAL INSURANCE

Dear Valued Patient:

Dental insurance is the most helpful as well and most misunderstood item in dental treatment today. Let us clear up some common misconceptions about your dental insurance.

Dental insurance is a contract purchased by your employer for your benefit. It has NO CONNECTION with our office. The extent of coverage and benefits provided varies greatly from company to company, and sometimes even within a company. It has absolutely nothing to do with services provided by the dentist and the fee charged for these services.

We will make every effort possible to assist you with your personal insurance coverage. As a courtesy, we will prepare and submit your insurance claims and will also provide estimates of expected insurance benefits. Estimates of personal financial responsibility for your dentistry will also be provided. Co-payments will be due at the time of treatment unless prior arrangements have been made. Since insurance estimates are not totally accurate, any overpayment will be refunded to you immediately. Any remaining balance may be funded when you receive your next statement. Should no insurance payment be made within sixty days of the submitted claim, the charges will become your sole responsibility. We will still continue to aid you in any way possible with your insurance.

If you have any questions pertaining to dental insurance, please feel free to talk with our front office staff.

By signing below I acknowledge I have read and understand the guidelines above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

STOP-Bang Questionnaire

Please answer the following questions by checking "yes" or "no" for each one

Snoring (Do you snore loudly?)

Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)

Observed Apnea (Has anyone observed that you stop breathing, or choke or grasp during your sleep?)

High Blood Pressure (Do you have or are you being treated for high blood pressure?)

BMI (Is your body mass index more than 35 kg per m2?)

Age (Are you older than 50 years?)

Neck Circumference (Is your neck circumference greater than 40 cm [15.75]?)

Gender (Are you male?)

Score 1 point for each positive response.

Scoring interpretation: 0 to 2 = low risk, 3 or 4 = intermediate risk, > or = 5 = high risk.

Your information will be encrypted.

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