ALLA AGAMOV DMD

FAMILY 8 COSMETIC DENTISTRY
47 POND STREET , SUITE 3
781-784-8435

OFFICE POLICIES

The following policies and procedures are in place to ensure that your care is as efficient and effective as possible.

APPOINTMENTS:

A scheduled appointment is a commitment of time between you and our practice. We have reserved that time just for you. When appointments are missed or cancelled, that time is permanently lost. We ask when you schedule an appointment that you make every effort to keep the commitment. We understand that personal emergencies sometimes occur, and we always take that into consideration when receiving a last minute cancellation. We truly appreciate your courtesy of giving us a 08•hour notice if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health and keeping your scheduled appointments allows us to be partners in your dental care.

It is our policy that with less than 48-hours notice on a change of commitment, with our dental hygienist a charge of $50.00 will be applied to your account. For Major appointments that are over a 1 1/2 or more, a charge of $100 will be applied to your account. The fee charged must be paid prior to receiving additional services at our office. After two or more missed or late appointments, your account will be reviewed and you may be released from our practice as a patient.

PAYMENT:

Payment is expected at the time of the visit unless other arrangements have been made in advance. We accept cash, check, credit cards, and Care Credit. If your account is 60 days past due and arrangements have not been made, we will turn over your account to collections.

Other office Charges: *Returned checks will be assessed a $25 processing fee

Alla Agamov D.M.D
47 Pond Street
Sharon, MA 02067

Patient HIPAA Consent Form

I understand that I have certain rights to privacy regarding my protected health information These rights are given to me under the Health Insurance Portability and Accountability Act of 1966 (HIPAA) I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out

• Treatment(including direct or indirect treatment by other healthcare providers involved treatment in my treatment);
• Obtaining payment from third party payers(e.g. My insurance Comp).
• The day- to day healthcare operations of your practice

I have also been informed of, and given the nght to review and secure a copy of your Notice of Privacy practices, which contains a more complete description of the uses and disclosures of my rights under HIPAA I understand that you reserve the nght to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the nght to request restrictions on how to protect my health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this content, in writing at any time. However, any use or disclosure that occurred pnor to the date I revoke this consent is not affected.

DENTAL REGISTRATION AND HISTORY

PATIENT INFORMATION

DENTAL INSURANCE 

Assignment and Release 

all insurance benefits, if any, otherwise payable to me for services rendered I understand that I am financially responsible for all charges wheather or not paid by insurance. I authorize the use of my signature on all insurance submission.

The above-named dentist may use my health care information and may disclose such information to the above named insurance company(es) and the agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below       

PHONE NUMBER

In case of emergency contact (Specify someone who does not live in your household.)

DENTAL HISTORY

Place a mark on yes or no to indicate if you have had any of the following 

HEALTH HISTORY

Place a mark on "yes" or "no" to indicate if you have had any of the following?

Women

MEDICATION

ALLERGIES

UPDATES (to be filled in at future appointments)

COVID-19 Pandemic Emergency Dental Treatment Consent Form

knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. I have been made aware of the Center for Disease Control guidelines, the recommendations of the Massachusetts Dental Society, American Dental Association, and Local/State Public Health Mandates that all non-urgent dental care is not recommended. At this time, dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. I understand that some dental infections, if left untreated, can lead to serious complications, including the need for hospitalization.

I confirm I am seeking treatment for a condition that meets these criteria

Procedure Issues

I understand that the treatment provided by my dentist is intended to ONLY eliminate or reduce the infection and/or pain that I am currently experiencing and may not be definitive care. There may be a need for additional procedures to return the state of my mouth to optimum health. Failure to seek additional treatment that my doctor recommends may result in further issues, including pain, infection, and loss of teeth/bone and/or function.

Due to the extreme nature of this pandemic, I understand that post-operative monitoring is difficult, in-office visits are not recommended, and that my doctor may opt to perform these services remotely.

After my procedure, I understand that I may be at higher risk for further infection and agree to be remain at home, in compliance with the state "Safer at Home" mandates.

I understand that to mitigate these risks, it is imperative that I take the medications as prescribed. I further understand that certain medications, such as opioid "pain" medications, cannot be called into pharmacies.

Unique Circumstances

Dental procedures create water spray (aerosol), which is how the disease is spread. The ultra- fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus by being in a dental office.

I confirm that I do not have any of the following symptoms of COVOID-19: fever, shortness of breath, dry cough, runny nose, sore throat currently, or for the last 14 days.

I confirm that I have not been in contact with a person that has been diagnosed with COVID- 19 within the last 14 days.

I understand that the CDC recommends social distancing of at least 6 feet to prevent transmission of disease and this is not possible with dentistry.

I agree that, if I were to exhibit any symptoms of, or am diagnosed with, COVID-19, I will immediately contact my dentist so that proper steps can be taken to limit the spread of this contagion.

I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed treatment will be completely successful in resolving my pain and/or infection. It is anticipated that the treatment will provide benefit in reducing the cause of this condition. However, due to individual patient differences and the extenuating circumstances, there exists a risk of failure relapse, selective retreatment, or worsening of my present condition, including the loss of additional teeth/bone, despite the best care.

I have read, comprehend, and agree with the above statements.