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PATIENT REGISTRATION FORM

Khanna Dentistry

425 Hamilton St.,
Geneva, IL, 60134
(630) 845-1088

Patient Information( * mandatory to fill )
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Responsible Party/Primary Insurance Subscriber Information( * mandatory to fill )


  •  Same as the Patient information

CONSENT

The undersigned hereby authorizes Dr. Khanna to take X-ray, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Khanna to make a thorough diagnosis of the patient’s dental needs. I also authorize Dr. Khanna to perform any and all forms of treatment, medication, and/or therapy that may be indicated. I also understand the use of an anesthetic agent embodies a certain risk.

I understand that payment is due in full at the time of service unless alternative financial arrangements have been made with Khanna Dentistry in advance in writing. I understand that late fee will be added to any overdue balances.

I understand that where appropriate, credit reports may be obtained.

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Medical History( * mandatory to fill )
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  •  Taking oral contraceptives?


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  •  sulfa drugs
  •  Local anesthetics
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Do you have, or have you had, any of the following?
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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 parents) health.nIt is my responsibility to inform the dental office of any changes in medical status.

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TMJ History( * mandatory to fill )
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PERSONAL DENTAL NEEDS SURVEY( * mandatory to fill )

Please rate on a scale of 1-5 the importance of each of the following regarding your dental care. (1 = most important)

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Please rate on a scale of 1-3 what a dentist must do to gain your confidence.

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  •  Music or Movie with headphones
  •  Nitrous Oxide
  •  Sedative Medications (oral and/or I.V.)
  •  Patient Education Material
  •  Neck Wraps
  •  Blanket
  •  Other

Are you concerned about the following

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Please check one answer for each of the following:

  •  The big picture
  •  Detail by detail
  •  What I see
  •  What others see
Financial Terms( * mandatory to fill )

Thank you for choosing Khanna Dentistry as your dental healthcare provider. We are dedicated to providing the highest quality of care possible. We are also committed to providing our patients clear and straightforward information regarding their financial responsibilities. The following is a statement of our Financial Terms that we require you to read and sign before treatment.

Patients without Insurance Coverage: Full payment is due at the time of service unless alternative financial arrangements have been made with Khanna Dentistry in advance and in writing. For your convenience, we accept cash, personal checks, and all major credit cards.

Insurance Patients: Dr. Khanna does not participate in preferred provider programs. Payment will be expected pay in full at the time of service and the insurance company will reimburse you directly. As a courtesy to you, we will submit all insurance claims and supporting documents to your insurance company. Please remember, it is still your responsibility to alert us of any changes in your insurance coverage. Please bring your insurance card and all pertinent information that will allow us to determine the benefits available to you or if there have been any changes in your benefits.

Returned Checks: Patients whose checks are returned from the bank due to non-sufficient funds will incur an additional fee of $35.00

Past Due Accounts: Past due accounts are referred to a collection agency. A collection fee ranging from $25 to up to 35% of all the balance due may be added to your unpaid balance to recover costs of collections. You will also be responsible for any and all attorneys’ fees, court costs and any other fees associated with the collection of your debt.

Extended Payment Plans: All extended payment plans are done through Care Credit, which is a third-party financing company. They offer a wide variety of payment options including some interest-free payment plans. If you have any questions about applying for a Care Credit account, please speak with our Treatment Coordinator.

Broken or Missed Appointments: An appointment is considered broken if it is not kept or if it is changed with less than 48 hours notice to us. Broken and missed appointments prevent other patients from receiving the dental care they require. Our practice takes all of our patients and their appointments seriously, so please be considerate and inform us at least 48 hours in advance if you need to change your appointment.

Fee for Missed Appointment if 48-Hour Notice is Not Given: To reschedule or cancel an appointment, you must notify us at least 48 hours in advance to avoid a missed appointment fee of $100.00.

If you have any questions regarding your account, please contact our office at 630-845-1088. Thank you for understanding and accepting our financial policy. 

I have read and agree to the terms of this Financial Term:

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PHOTO RELEASE FORM( * mandatory to fill )

Neeraj Khanna DDS

Khanna Dentistry, P.C.

425 Hamilton St

Geneva, IL 60134

Permission to Use Photographs

Subject: Dental Photography

I grant Dr. Neeraj Khanna DDS, its representatives, and team members the right to take photographs of me, my mouth and teeth in connection with the above-identified subject. I authorize Dr. Neeraj Khanna, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically.

I agree that Dr. Neeraj Khanna DDS may use such photographs of me with my name for any lawful purpose; including, for example, such purpose as educational lecturing, illustration, advertising, and Web content.

I have read and understood the above:



  •  I Refuse to release the information
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APPOINTMENT AGREEMENT( * mandatory to fill )

Our time is valuable and so is yours. Our commitment to you is:

• We always try to make appointments that are convenient for you.

• We will not ask you to make a schedule change unless it is an extreme emergency or of a potential benefit to you.

• We will always be respectful of your personal time and will make every effort to start your dental appointments on time and complete your treatment as efficiently as possible.

Please understand that we reserve chair time just for you when you make an appointment with us. In an effort to continually provide quality service, we ask that you keep your reserved time as it is scheduled. Please give our office 48 hours(or more, if possible with the exception of extreme personal emergency) notice if you need to change your appointment or a fee will be assessed to your account based on the amount of time scheduled, at the rate of $100 per hour.

Please keep us informed of any changes to your health information and medications as well as your address, phone, email or insurance information so that we may serve you in the best possible manor.

I have read and understand the above financial policies. I authorize release of any information pertaining to treatment for the purpose of comprehensive filing of insurance claims. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me. I acknowledge full responsibility for the payment of services at the time of service unless other arrangements are made with this office. 

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CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION( * mandatory to fill )

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT-PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decided whether to sign this Consent. Our Notice provides a description of our treatment, payment, activities and healthcare operations of the uses and disclosures we may make of your protected health information and other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting:

Contact Person: Office Coordinator/Practice Manager

Phone: 630-845-1088 Fax: 630-845-1088

Address: 425 Hamilton Street, Geneva, IL 60134

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent.

I, 

, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent Form I am giving my consent to your use and disclosure of my protected health information to carry out treatment; payment activities and health care operations.

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DENTAL BENEFIT AGREEMENT( * mandatory to fill )

Your dental benefits help offset the investment of getting quality dental care performed on you and your family and it is our pleasure to assist you in maximizing your insurance benefits by completing your claim forms. Please be aware that your coverage depends solely on what your employer wishes to purchase. Some plans cover as little as 30% or as much as 100% of dental services, with most falling in the 40%-80% range. Some plans base the amount of benefit on the schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan.

For example, if your plan states that it will pay 80% of the cost of a specific treatment, it means 80% of the fee arbitrarily determined by the insurance company and not the actual fee charged by a dental office, ours or otherwise. Please understand that any assistance concerning what or how much coverage you have, whether by phone or mail, is for reference only and should not be your only basis for proceeding with or denying treatment.

We do not base our treatment recommendations on what the insurance company will cover but rather what the best treatment is for you. We will assist you in any way that we can (including electronic claims submission and submitting pre-determinations). In addition, because of the inconsistencies in secondary insurance benefits, we do not consider the secondary benefits when figuring your potential portion of the charges.

Thank you for understanding! 

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