Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

Patient Registration Form

Allure Dental, LLC

171 Elden St. Ste. 2c3, Herndon, VA 20170,
Herndon, VA, 20170
(703) 956-6168

Patient Information( * mandatory to fill )
  •  E-mail
  •  Text
  •  Cell
  •  Work
  •  Home
  •  Insurance
  •  Internet
  •  Mailer
  •  Referral
Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Please select below( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Self
  •  Other
Primary Insurance Details( * mandatory to fill )
Secondary Insurance Details( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Authorization Statement and HIPPA Privacy Notice( * mandatory to fill )

I hereby authorize Allure Dental, LLC and Dr. Ayoubi to provide dental services to me and my dependants and apply for benefits on my behalf for covered services rendered. I request that the payments from my insurance company be made to the above named corporation and/or provider(s). I certify that the information that I have provided above is correct and further authorize the release of any necessary information including medical, dental and insurance coverage information to my insurance company in order to determine my insurance benefits to which I may be entitled. I authorize the provider to initiate a complaint to the Insurance Commissioner for any reason on my behalf. A photocopy of this assignment shall be considered as effective and valid as the original, this authorization may be revoked at any time in writing. I understand and agree that (regardless of my dental insurance status or coverage), I am ultimately responsible for the balance on my account and my dependents for any dental services rendered. If my account becomes past due I agree to pay all costs of collections and litigations if any. I understand that if my account is delinquent I will be charged an additional 33% to cover collection expenses. I have read this entire sheet and have completed the above answers. I certify that this information is true and correct to the best of my knowledge and I will notify Allure Dental, LLC of any changes in my status or the above information.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )

HIPPA STATEMENT

 

I have read and agree with Allure Dental, LLC’s HIPPA Notice of Privacy Policy. I hereby authorize Allure Dental, LLC to furnish to my insurance company or authorizing agency information regarding my protected health information for the purposes of treatment, payments, or health care operations. I further authorize the dentist(s) of Allure Dental, LLC to consult as needed in their sole discretion with other medical providers regarding my medical care.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )

For your convenience, we offer the following methods of payment:

Debit Card • MasterCard • Visa • Cash

Payment is expected at time of service. Thank you.

Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important impact on dental treatment. Thank you for answering the following questions.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Pregnant
  •  Trying to conceive
  •  Nursing
  •  Taking hormonal contraceptives (oral, patch, or other )
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  Metal
  •  Latex
  •  Local Anesthetics
  •  Sulfa Drugs
  •  Other
Do you have, or have you had, any of the following?
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  N / A

* Condition may require medication.                                  N/A – Not answered by patient

  •  2007 American Heart Association Guidelines do not require prophylactic antibiotics prior to most procedures. Notify us if you have a special situation.
Patient Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

I certify that I have read and understand all of the above and that I have answered all of the questions accurately. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child, during the period of such dental care to third party payors and/or health practitioners. I hereby authorize Dr. Ayoubi and her staff to examine, take x-rays, and do any necessary treatment. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedure or dental treatments performed.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
Appointment and Cancellation Policy( * mandatory to fill )

When we make your appointment, we are reserving a time and dental exam room for your particular needs. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved room to another patient who needs to be seen.

Missed appointments and cancelled appointments without 24 hours notice are subject to a cancellation fee of $40. If you are more than 15 minutes late to your appointment, you will not be seen that day and will be charged a fee of $40. Repeat cancellations or missed appointments will result in dismissal from the practice.

We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. Please sign that you read and understand our Cancellation Policy. Thank you!

I have read the above information regarding the Appointment Cancellation Policy and agree to its terms.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
Financial Policy( * mandatory to fill )

Insurance policies generally cover only a portion of the total treatment cost. Please remember that your dental insurance policy is an agreement between you and your insurance company, not between your insurance company and our office. We make no guarantee of any estimated coverage, and it is your responsibility to understand your plan and insurance benefits. Please keep in mind that you are responsible for your total obligation of fees for treatment provided should your insurance benefits result in less coverage than anticipated. If you would like to know what your expected coverage will be, we can submit a pre‐authorization estimate to your insurance company. Your insurer will usually respond and send a detailed explanation of benefits within 4‐6 weeks.
Unless other arrangements have been made, we ask that you pay your portion of the bill at the time of treatment. It is your responsibility to pay any balance not paid by your insurance company. For your convenience, we accept payments made with cash, debit cards, Visa and MasterCard.

ALL ESTIMATED PAYMENTS (DEDUCTIBLES, CO‐PAYS, AND CO‐INSURANCE’S) ARE DUE IN FULL AT THE TIME OF SERVICE. ALL PAYMENTS ARE AN ESTIMATE AND ARE FINALIZED ONCE THE INSURANCE PROCESSES THE CLAIM.

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

You may Refuse to Sign This Acknowledgement

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

(Please click below to draw/upload sign)
(Your IP Address : IP:54.226.58.177 )
Copyright ©2019 SRS Web Solutions
Your browser doesn't support signing