Patient Information

Insurance Information

Emergency Contact

Whom should we thank for referring you to our practice?

I, the undersigned, acknowledge that I received the Dental Board of California’s Dental Materials Fact Sheet.

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Signature of patient / Guardian

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Signature of Staff

So we may bill insurance directly, I hereby authorize payment directly to Smile Dental Practice of the insurance benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by this Insurance Company. I authorize Smile Dental Practice and release all the necessary information relating their claims.

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Signature of patient / Guardian

Medical Alert

Please select each box, yes or no, please do not leave it blank

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Signature of patient / Guardian

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Doctor's Signature

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Doctor's Signature

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patient's Signature

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Doctor's Signature

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patient's Signature

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Doctor's Signature

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patient's Signature

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Doctor's Signature

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patient's Signature

SMILE DENTAL PRACTICE PATIENT DENTIST ARBITRATION AGREEMENT

Article I. It is understood that any dispute as to dental malpractice, that is as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties of this contract, by entering into it are giving up their constitutional right to have any such dispute decided in a court oflaw before a jury, and instead are accepting the use of arbitration.

Treatment in the oflice is contingent upon both parties consenting to this Arbitration Agreement.

A. Parties to the Agreement:

Article II. The term "Patient" as used in this Agreement includes the undersigned individual, his or her spouse, children(whether bom or unborn), and heirs, assigns, or personal representatives. The individual signing this Agreement signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law. The term "Doctor" as used in the Agreement includes the undersigned Doctor and his or her professional corporation or partnership, all independent contractors who practice dentistry at the undersigned Doctors place of business, and any employees agents, successors in interest, heirs and assigns of the foregoing individuals or entities. The Doctor signing this Agreement signs it on behalf of all the foregoing individuals and entities, intends to bind each of them to arbitration to the full extent permitted by law.

B. Treatment Covered:

Patient understands and agrees that any dispute of the sort described in Article I between Doctor and Patient will be subject to compulsory, binding arbitration.

C. Coverage of Pre-Natal Claims (if Applicable): Patient understands and agrees that, if Doctor treats her during pregnancy, any dispute of the sort described in Article I as to dental treatment rendered to have affecting the unborn child will be subject to compulsory, binding arbitration.

Article Ill.

A. Informal Resolution of Disputes:

In the event Patient feels that a problem has arisen in connection with the dental care rendered by Doctor to Patient, Patient will promptly notify Doctor so that Doctor may have the opportunity to resolve the matter. Notice may be given orally or in writing, and shall stop the running of the statute of limitations for ( 90) days.

B. Method of Initiating Arbitration:

If the dispute is not resolved by mutual agreement within ninety (90) days, patient may initiate arbitration by notifying doctor to that affect. The arbitrator must be selected within twenty-one (21) days of the signature under receipt for a letter sent certified mail return receipt request demanding that dispute submitted to arbitration. Following the selection of the arbitrator, arbitration must be held within thirty (30) days.

C. Applicable Law:

The arbitration shall be conducted pursuant to the California Arbitration Act. (C.C.P 1280-1296). The arbitrators shall, in addition, have authority to order such other discovery as he/she deemed appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law of the State of California including the provisions of the Medical Injury Compensation Reform Act of 1975 which shall apply to the same extent as if the dispute were pending before a superior court of the State of California. The arbitrator shall not have the power to commit errors of law or legal reasoning, and the arbitrator's decision may be vacated or corrected pursuant the California Code of Civil Procedure Sections 12806.2 or 12086.6 for any such error. The prevailing party shall be entitled to attorney fees.

Article IV

A. Revocation:

If you are signing this agreement and then change your mind, the law permits you to revoke the Agreement, providing you give your doctor written notice within thirty (30) days of signing that you want to withdraw from the Agreement. However, doctor and patient agree that any claim arising from dental services rendered prior to revocation shall be subject to arbitration. Furthermore, doctor is not obligated to continue the doctor/patient relationship should you decide to withdraw from the agreement.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGRREING TO HAVE ANY ISSUUE OF DENTAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP RIGHT TO JURY OR COURT TRIAL, C ARTICAL I OJ.' THIS CONTRACT.

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Patient /Legal Guardian Signature

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Witness Signature

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (164.5O8(a))

I, (patient’s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

  • a basis for planning my care and treatment;
  • a means of communication among the health professionals who may contribute to my healthcare;
  • a source of information for applying my diagnosis and surgical information to my bill;
  • a means by which a third-party payer can verify that services billed were actually provided;
  • a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this faciliy’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (164.5O6(a))

I understand that:

  • I have the right to review this facility’s Notice of Information practices prior to signing this consent:
  • This facility, reserves the right to change the notice and practices and that prior to implementation will mall a copy of any revised notice to the address I’ve provided if requested.
  • I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
  • I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
  • It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

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Signature of Patient or Legal Representative Witness

HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form

Acknowledgement of receipt of Information Practices Notice (§164.520(a))

I, (patient’s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

  • I have the right to review this facility’s Notice of Privacy Practices prior to signing this acknowledgement;
  • this facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I’ve provided if requested.

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SIGNATURE of Individual or Legal Representative Witness

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Witness Signature

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because:

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HIPAA Officer Signature

Appointments and Cancellations Agreement

When we make your appointment, The Doctors and office staff time is reserved. 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 would like it.

There is a charge for not showing up for scheduled appointments. Repeated cancellations or missed appointments will result in loss of future appointment privileges. A $40 charge wiU apply for catu:elation with less than 24hrs Notification.

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 We respect your time we, of course, would appreciate the same courtesy from you.

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Signature

Release

I, , grant Smile Dental Practice a license to reproduce and use any photographs, still or video images, or audio recordings for me, and any testimonial I issue regarding my health care services at Dental Office(the "Marketing Materials"), for any of the following purposes:

Dental Office website, social media, online and printed articles, mass advertising mailings, brochures, booklets, flyers, event displays and other similar marketing materials and I or activities directed to prospective patients within a 100 miles radius of Dental Office.

Dental Office is authorized to use all or any portion of the Marketing Materials without royalty or recompense of any kind, in unlimited quantities and for an unlimited period oftime.

I release Dental Office and any of its associated or affiliate companies, their owners, directors, officers, agents, employees and appointed advertising agencies from all claims of any kind arising out of the use of the Marketing Materials as described in this Release.

In the event I want Dental Office to cease using the Marketing Materials, I understand I must provide 60 day written notice to Dental Office to discontinue use of the Marketing Materials during the 60 day notice period and shall further have the right to exhaust its supply of products containing any portion of the Marketing Materials ordered or received prior to Dental Office's receipt of written notice.

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Signature

Consent Form

1. Initial appointment for

2. Changes in Treatment Plan

I understand that during treatment, it may be necessary to change or add procedures due to condition found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

3. Drugs and Medications

I understand that antibiotics, anesthetics, analgesics and other medications can cause allergic reaction causing redness, swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction) or interact with other medication taken. Injection might cause temporary or permanent parasthesia, numbness or loss of the taste.

I understand that occasionally upon injection of local anesthetic I might have temporary or permanent parasthesia, numbness, irritation or loss of the taste.

I understand that medications, drugs and anesthetics may cause drowsiness and lack of coordination increased by the use of alcohol or other drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous devise while taking medication and/or drugs, or until fully recovered from their effects at least twenty-four hours after treatment.

4. Hygiene and Periodontal loss (Tissue and Bone)

I understand that I have a serious and progressive disease that can lead to acute infection, pain and tooth loss. Treatment can include cleanings (scaling), deep cleaning (root planning) and periodontal surgery(by referral to a specialist). Teeth that do not respond favorably to treatment will require extraction.

I understand that post-therapy, my teeth may be sensitive to cold sweets.

I understand that the long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e. brushing and flossing) and maintaining regular recall visits, therefore the results can not be guaranteed.

5. Endodontic Treatment (Root Canal)

I realize there is no guarantee that root canal therapy will save my tooth, complications ( i.e. calcified canals, inaccessible canals, perforation and loss of the canal during treatment, instrument separation inside of the canal and/or fracture of the tooth, crown, body or root) can occur. I further realize that occasionally root canal filling material may extend through the root or it may not be possible to completely fill the root. Other complications can include a reaction to a medication used, pain, swelling, continued infection and sensitivity to pressure even after treatment is completed. Risk of temporary or permanent numbness in treatment area.

If “open and medicine” or pulpotomy procedure is performed, I understand this is not a permanent treatment, and I need to pay for, and finish root canal therapy. If root canal treatment is not finalized, I expose my self to infection and/ or tooth loss.

If failure of root canal therapy occurs, the treatment may have to be redone, root-end surgery may be required by a specialist, or the tooth might be extracted. I understand that the tooth might be lost in spite of all the efforts to save it. Failure to restore the tooth after root-canal treatment (i.e. crown) could lead to decay, infection and premature loss of the tooth.

6. Crowns, Bridges, Inlays, Onlays and Veneers

I understand sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand I may be wearing temporary crowns, which may come off easily, and I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size, and color) will be before cementation. I understand if I do not return for my scheduled appointment for delivery of my crown or bridge within 20 days from time of preparation it may not fit properly, and I will be responsible for any lab fees incurred, if a remake becomes necessary.

I understand that crowns and bridges need periodic and proper oral hygiene and cleaning, otherwise decay may develop underneath or around the margins of the restoration, leading to further dental treatment.

I realize that permanent crowns are fabricated from materials that can be susceptible to fracture. sensitivity to heat, cold or pressure which will require root-canal treatment. The new crown may alter the way you bite fits together and make your jaw joint feel sore which may require adjusting the bite.

7. Implants

I understand that implants have two main parts: an abutment (root form) and restoration (suprastructure) portion. Poor healing or infection at the surgical site can lead to acute infection, pain and loss of the abutment and/or adjacent teeth. The restorative portion also may come lose or fracture requiring replacing screws or collars, recementation and/or complete loss of the suprastructure. Replacement of the abutment or suprastructure are additional procedures, the cost of which is my responsibility. I understand that smoking greatly increases the risk of abutment failure.

8. Dentures, Partials

I realize full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new denture (including shape, fit, size, placement, and color) will be the “teeth in wax”-”try-in”visit. I understand most dentures require relining approximately three to six months after initial placement and yearly thereafter. The cost for these relines is not included in the initial denture fee.

Following-up appointments are integral part of maintenance and success of prosthetic appliance. Persistent sore spots should be immediately examined by a doctor. I further understand that surgical interventions i.e. tori (bone) removal, bone re-contouring or implants may be need for dentures to be properly fitted. I understand that due to bone loss or other complicating factor, I may never be able to wear dentures to my satisfaction.

Stayplates: I understand that stayplates are least expensive way of replacing missing teeth with a removable appliances. I understand that these appliances are made of acrylic and are bulkier in size and more fragile and prone to fracture. I understand that cast partial dentures or valplasts are better alternative to stayplastes in regards to durability, comfort, esthetic allergic reaction. Immediate denture (placement of denture immediately after extraction) are painful and will require frequent adjusting, redness, while the tissue is healing.

9. Fillings

I have been advised of the need for filling to replace tooth structure lost to decay. I understand that with time, filling will need to be replaced due to wear of the material. In cases where very little tooth structure remains, or existing tooth fractures off, I may need to receive more extensive treatment such as root canal therapy, post and build-up and crowns, the cost of which is my responsibility.

10. Removal of teeth

Alternatives to removal have been explained to me (rot canal therapy, crowns, periodontal surgery, etc.), and authorize the Dentist to remove the recommended teeth # and any others necessary due to a change in treatment plan. I understand removing teeth does not always remove all of the infection, and it may he necessary to have further treatment. I understand the risks involved in having teeth, removed, some of which are pain, swelling, spread of infection, dry socket, fractured jaw, or loss of feeling (temporary or permanently). I understand I may need further treatment by specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility. Potential risks include, but are not limited to the following:

  1. Post-operative discomfort; swelling; prolonged bleeding; tooth sensitivity to hot or cold; gum shrinkage (possible exposing crown margins); tooth looseness; delayed healing (dry socket) and/or infection (requiring prescriptions or additional treatment, i.e. surgery).
  2. Injury to adjacent teeth, caps or fillings (requiring the recementation of crowns, replacement of fillings, fabrication of crowns or extraction) or injury to other tissues not within the described surgical area.
  3. limitation of opening; stiffness of facial and/or neck muscles; change in bite; or temporomandibular joint (jaw joint) difficulty (possibly requiring physical therapy or surgery).
  4. Remaining residual root fragments or bone spicules which will require another surgery.
  5. Possible bone fracture which may require wiring or surgical treatment.
  6. Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
  7. Injury to the nerve underlying the teeth resulting in itching, numbness or burning of the lip, chin, gums, cheek, teeth and/or tongue on the operated side; this may persist for several weeks, months or in remote instances, permanently.

I understand that dentistry is not an exact science and therefore, practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made by Dr. Edik Haghverdian regarding dental treatment, which I have requested and authorized. I understand that no guarantee or assurance has been given that the proposed treatment will be curative and/or successful to my complete satisfaction. I agree to cooperate completely with the recommendations of the doctor for optimum result, risks, benefits and alternative treatment (including doing nothing) has been explained to me. I have my satisfaction. I have no unanswered questions about treatment benefit/ risks, or alternative treatment(s) and their benefits/risks. I have read, understand and agreed to it.

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Signature of Dentist

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Signature of the Witness

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Signature of the Patient