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PATIENT REGISTRATION

ismile dental care

1050 Galloping Hill Rd Suite #103,
Union, NJ, 07083
9087683057

Patient Details( * mandatory to fill )
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HUSBAND, FATHER OR RESPONSIBLE PARTY (IF OTHER THAN PARENT)( * mandatory to fill )
WIFE, MOTHER OR RESPONSIBLE PARTY (IF OTHER THAN PARENT)( * mandatory to fill )
NEAREST RELATIVE( * mandatory to fill )

AUTHORIZATION

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I authorize the release of any information concerning my (or my childs) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I authorize the release of any information concerning my (or my childs) health care, advice and treatment to another dentist.

I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payments of services not paid, in whole or in part by my dental care payer.

I attest to the accuracy of the information on this page.

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DENTAL HISTORY( * mandatory to fill )

Please check if you have/had

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MEDICAL HISTORY( * mandatory to fill )
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WOMEN

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MEDICAL HISTORY( * mandatory to fill )
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AUTHORIZATION AND RELEASE( * mandatory to fill )

I have read and answered the above questions to the best of my knowledge.

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PATIENT HIPAA AWARENESS( * mandatory to fill )

With my permission, Dr.beheiry & Dr.Baghaei use and disclose protected health information(PHI) about me to carry out treatment, payment and healthcare operations(TPO). Please refer to Drs. Beheiry & Baghaei's Note of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Beheiry & Baghaei reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Drs. Beheiry & Baghaei may call my home or other designated locations and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my permission the office of Drs. Beheiry & Baghaei may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Or Confidential.

With my permission, the office of Drs. Beheiry & Baghaei may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Drs. Beheiry & Baghaei restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, I am allowing Drs. Beheiry & Baghaei to use and disclosure my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

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APPOINTMENT POLICY( * mandatory to fill )

Our staff at iSmile Dental Care is committed to providing the highest quality of dental care and services for our patients. Dental procedures require preparation and planning. This includes appropriate staffing, treatment room availability and material preparation at specific times during our work day. We reserve specific time blocks in an attempt to meet patient schedules and the urgency of the dental need. If you have made an appointment with us, that time has been reserved exclusively for you and we have prepared in advance for your visit. Please be advised of the following requirements:

• We require  hours notice for cancellation of a scheduled appointment

• A cancellation fee of $75.00 will be added for all missed or cancelled appointments with less than 48 hours notice. A ppointments longer than 60 m inutes will result in a higher fee

• If there are three missed or cancelled appointments without  hours notice appointments in a year time frame, we reserve the right to not schedule any further appointments or to require a deposit in order to schedule a future appointment.

• Family emergencies will be taken into consideration

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FINANCIAL POLICY( * mandatory to fill )

At iSmile Dental, our ultimate goal is your dental health and wellness. That's why we always present you with the best dental solutions possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental insurance benefits but some do not. If you have dental benefits, congratulations! You are extremely fortunate. Here are some important points you should know:

- Your dental benefits are based upon a contract made between you and an insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. They are meant only to assist you.

- We currently accept a large number of PPO insurance plans. This means we work with literally hundreds of companies. Although we can maintain computerized histories of payments by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have but it is ONLY AN ESTIMATE. If you would like to exact out of pocket figures, we can submit a pretreatment authorization with your insurance company. Keep in mind this is not a guarantee of coverage and it may delay treatment.

- We will bill your insurance company as a courtesy. If insurance does not pay within 90 days, iSmile Dental reserves the right to request payment in full for services from you and let you collect the insurance funds due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

- iSmile Dental does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover, cash, and checks. If you are in need of payment plans, we also work with CareCredit which offers 6 or 12 months same as cash no interest financing. Our staff can assist you in the application process.

- A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hours notice to avoid a $20 cancellation fee.

 I have read and agree with the above conditions.

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