• PATIENT REGISTRATION AND MEDICAL HISTORY

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  • In ease of Emergency, contact (specify someone who does not live in your household)

  • DENTAL INSURANCE

  • Primary insurance

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  • Secondary Insurance

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  • Assignment and release

  • I certify that I, and/or my dependents(s) have insurance coverage with      And assign directly to Dr. Surbhi Chandna all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I
    am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their 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  

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  • DENTAL HISTORY

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  • FINANCIAL POLICY

  • Our commitment is to provide quality dental care to the entire family though exceptional
    service and the utilization of advance technology.

    Methods of payment

    1. Cash, Check, or Credit card (Visa, MasterCard)
    2. Dental insurance (described below)
      Payment is required when services are rendered unless prior financial arrangements have been made.

    Dental insurance (where applicable)

    1. We are please you have dental insurance, and our office will assist you in obtaining the maximum benefits specified in your contract. However, your insurance contract is between you, your employer, and the insurancecompany.
    2. As a courtesy to you, we will file your insurance and accept assignment of benefits. We ask that your estimated co-payment and deductible be paid at the time of service.
    3. Not all services are covered benefit in all contracts.

    Related information

    1. For return checks, a charge of $25.00 will be applied and balances older than 60 days may be subject to additional interest charges.
    2. In the event that the account is not paid and we refer the account to collection, you will be responsible for a $25.00 fee incurred for the collection of your bill (i.e., attorney fees, court fees, and collection agency fees)
    3. We reserve the right to charge $50.00 for appointments canceled or broken without 48 hours of notice. This fee covers only a portion of the overhead such as salaries, electric, heat, etc., which still has to be paid whether you are present or not. Once an appointment has been made please remember that this time has been reserved exclusively for you.

    I have read and understand the above information. I understand that I am responsible (regardless of my insurance) for any charges incurred from services rendered. I agree to be responsible for any charges not paid by my dental plan. I understand that should my account be placed with an agency or attorney for collections, then I agree to be responsible for all cost incurred in the collection of my account, including attorney’s fees, interest at 1.5% per month (18% per annum), and all court costs.

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  • HEALTH HISTORY

  • ALLERGIES

  • OFFICE POLICY AND FINANCIAL AGREEMENT

    If you are unable to keep an appointment, we ask that you kindly provide us with at least 48 Hours notice. This courtesy on your part will make it possible to give your appointment to another patient. Patients will be billed for late cancellations and or no-shows. Please schedule only definitive appointments. Same day or next day appointments will be given, based upon availability. We are closed on Fridays, weekends and major holidays. As every effort is made to be on time for our patients, we ask that you extend the same courtesy to us by arriving a few minutes before your scheduled appointment. Co-payments and co-insurances are due at the time services are rendered. Forms of payment accepted by the office are check, Debit Card, Visa and MasterCard Credit Cards.

  • I,    FULLY UNDERSTAND DR CHANDNA’S OFFICE POLICIES ANDFINANCIAL AGREEMENT.

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  • Informed Consent for General Dental Procedures

    You, the patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment.

    Do not consent to treatment unless you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

    It is very important that you provide your dentist with accurate Information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals co other dentists of specialists, and return tor scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome,

    Please read and initial the items below and sign at the bottom of the form.

  • 1. Treatment To Be Provided

  • 2. Drugs And Medications

    I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues: pain, itching, vomiting, and/or anaphylactic shock (severe allergic
    reaction).

  • 3. Changes in Treatment Plan

    I understand that during treatment it may be necessary to change or add procedures because of
    conditions found while working on the teeth that were not discovered during examinations, the most
    common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes as necessary.

  • 4. I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable. Patient’s Initials

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  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    "You May Refuse to Sign This Acknowledgment"

  • I,      have received a copy of this Office’s Privacy Notice

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