Aziz Bohra, DMD, MS

13065 W. McDowell Suite A101, Avondale, Arizona 85392

623-935-0004

Your ultimate team for Modern Periodontics

Patient Name:
Date of Birth
Gender
SS #
Email
Address
City
State
Zip
Home Phone Number
Cell Phone
Work Phone
Employer
Address
Occupation
If Minor, Name of parent or legal guardian
Relationship
Single / Married / Divorced / Other Spouse Name
Emergency Phone
Whom may we thank for referring you?
Dentist Name

DENTAL BENEFITS INFORMATION

Primary

Dental Benefit Company
Phone Number
Address
City
State
Zip
Name of Policy Holder
Relationship to Patient
Policy Holder’s ID# or SSN#
Member’s Date of Birth
Group#

Secondary

Dental Benefit Company
Phone Number
Address
City
State
Zip
Name of Policy Holder
Relationship to Patient
Policy Holder’s ID# or SSN#
Member’s Date of Birth
Group#

CONSENT FOR SERVICES

I UNDERSTAND THAT PAYMENT FOR DENTAL SERVICES PROVIDED BY THIS OFFICE FOR EITHER ME OR MY DEPENDENT IS MY RESPONSIBILITY AND DUE AT THE TIME SERVICES ARE RENDERED.

I UNDERSTAND THAT ALL DENTAL SERVICES PROVIDED ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR THE ENTIRE COST OF TREATMENT. AS A COURTESY, THIS OFFICE WILL ASSIST ME WITH PREPARING MY INSURANCE FORMS AND WILL MAKE EVERY EFFORT IN OBTAINING REIMBURSEMENT FROM MY INSURANCE COMPANY. I UNDERSTAND ANY DEDUCTIBLE AND ESTIMATED CO-PAYMENTS ARE DUE IN FULL AT THE TIME OF SERVICE.

I give my consent to West Valley Periodontics to receive payment directly from my insurance company, but understand that this office cannot render services based on the assumption that insurance company will pay. I agree to notify the office immediately if there are any changes regarding my dental benefits.

I hereby authorize West Valley Periodontics to release any of information that may be required by my dental benefits company, third party and/or healthcare provider.

I have read and understand the above conditions regarding my dental benefits.

Patient's Signature:

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Date:

Parent or Legal Representative Signature:

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Date:
Patient’s Name
DOB
Date
Reason for your visit today
Are you in dental discomfort
Referring Dentist
Phone Number
Email

Check if you have had problems with any of the following:

Bad Breath
Bleeding Gums
Periodontal treatment
Sensitivity to sweets
Temperature sensitivity
Clenching or grinding of teeth
Sensitivity when biting
How often do you brush?
Floss?
How do you feel about the appearance of your teeth?
Any adverse reaction during or in conjunction with a medical or dental Procedure

MEDICAL HISTORY

Physician’s Name
Phone #
Any serious illness or operations
Date
Blood Transfusion
Artificial Joints
Date
Cancer
Heart Attack
Date
Heart Surgery
Date
Stroke
Date
Pacemaker
Neurologic/Emotional Condition

Do you currently experience any of the following symptoms?

Other

ALLERGIES

Other

MEDICATIONS – Please list all medications you are taking

OFFICE FINANCIAL POLICY

Our goal at West Valley Periodontics is to ensure that you have an outstanding experience in our office. We are committed to supporting you in understanding your dental health, so that you will always be able to make the best choices in regards to your treatment.

We are here to assist you in any way possible. Please make your questions and concerns known to our team.

  1. I understand that payment for dental services provided by this office for either me or my dependent is my responsibility and due and payable at the time services are rendered.
  2. Patient with dental insurance: I understand that all dental services provided are charged directly to me and that I am personally responsible for entire cost of treatment. As a courtesy, this office will assist men with preparing my insurance forms and will make every effort in obtaining reimbursement from my insurance company. I understand any deductible and estimated co-payments are due in full at the time of service.
  3. I give my consent to allow West Valley Periodontics to receive payment directly from my dental benefits company, but understand that this office cannot render services based on the assumption that a dental benefit company will pay. I agree to notify the office immediately if there are any changes regarding my benefit coverage.
  4. As a condition of my treatment by this office, any financial arrangement must be made in ADVANCE, prior to the actual treatment. I understand the practice depends upon financial reimbursement from its patients.
  5. A finance charge of 3% per month on the unpaid balance will be charged on all accounts exceeding 30 days, unless a previously written and signed financial agreement exists and is being satisfied. I further agree to pay all financial charges, collections cost, attorney fees, and any other costs that may incurred to enforce collection of any amount outstanding on my account.
  6. I agree to pay the fee of $35.00 for any returned checks.
  7. I agree to pay the fee of $45.00 if I fail to give at LEAST 24 hour notice upon cancelling or rescheduling my appointment.
  8. All emergency services, or any other dental services performed without previous financial arrangements, must be paid for in full at the time of services.
  9. I authorize West Valley Periodontics to release any of my information that may be required to my dental benefits company, third party payer and/or healthcare practitioner.
  10. I grant my permission to West Valley Periodontics or your assignee to telephone me at home or at my work to discuss matters related to this form.
  11. I have read the above conditions of treatment and agree to their content.

Patient Signature:

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Date:

Parent/ Legal Representative Signature:

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Date:
Treatment Co-ordinator
PATIENT NAME
DATE OF BIRTH

I VERIFY THAT THE INFORMATION GIVEN ON HEALTH HISTORY FORM IS TRUE AND CORRECT.

  • I understand that the office and staff of West Valley Periodontics will make every reasonable effort to protect my personal health information, including my social security number, date of birth, address and phone numbers.
  • I understand that there may be times when the doctor and staff will need to speak with me regarding an appointment time, a test result, or financial arrangements. If I am not available, they have my permission to leave a brief message at my home or work number provided
  • I give my permission to West Valley Periodontics and staff to correspond with my general dentist, general physician, or specialist that I am under care with.
  • Upon my request, I will be given a full and complete copy of HIPAA privacy policy.

In addition to my dentist, physician and dental benefit company, I authorize West Valley Periodontics to discuss my personal information with the following people:

NAME
RELATION
NAME
RELATION
NAME
RELATION

Patient Signature:

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Date:

Parent/ Legal Representative Signature:

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Date:

FOR OFFICE USE ONLY


Signature of Witness

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Date: