Patient Registration Forms

Please correct the errors described below.

Patient Information

Employer/Insurance Information:

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Heath problems that you may have, or medications that you may be taking, could have an important interrelationship with the care you will receive. Thank you for answering the following questions.

Women: Are you...


Do you have, or have you had, any of the following?

Dental Health History

(Name and location)

Have you experienced any of the following problems in your jaw?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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.

Payment Policy

TO ALL OUR PATIENTS:

Our office policy is to have payment at time of service. I recognize that I am responsible for charges incurred today.

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.

I recognize that office policy requires a 48 hour notice to cancel an appointment without incurring a fee. I understand that the office may refuse to reschedule if there is a history of broken appointments.

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.

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PATIENTS WITH INSURANCE COVERAGE:

This office recognizes how difficult it is to understand the specifics of today’s insurance policies and will work with you to obtain the maximum benefits available. Please be aware that some, and perhaps all, of the services provided may be non-covered services or not considered “reasonable and customary” under your dental insurance policy.

It must be understood, however, that the contract is made between the insurance company and the patient. Therefore, it becomes the patient’s responsibility for knowing the details of coverage.

In the event a service is rendered that is not covered by my insurance company, I will be financially liable for this dental service. I also understand that my copayment and deductible are due at the time service is rendered.

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.

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I hereby authorize payment of the dental benefits otherwise payable to me directly to:

Arash Khani, D.D.S. P.A.

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.

Your information will be encrypted.

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