(IF SAME AS ABOVE, PLEASE SKIP)
PLEASE ANSWER ALL QUESTION, CHECK YES OR NO AND FILL IN BLANK SPACES WHERE INDICATED. ANSWER TO THE FOLLOWING QUESTIONS, OUR RECORDS WILL BE CONSIDERED CONFIDENTIAL.
HAVE YOU HAD OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING CONDITIONS?
Are you taking any of the following:
Are you allergic or have reacted adversely to the following:
NOTE: ANTIOBIOTICS (SUCH AS PENICILLIN)
MAY ALTER THE EFFECT OF BIRTH CONTROL PILLS. CONSULT YOUR PHYSICIAN/GYNECOLOGIST FOR ASSITANCE.
I HAVE FILLED OUR THIS QUESTIONNAIRE COMPLETELY, I HAVE ADVISED AND WILL ADVISE IN THE FUTURE TO WILSHIRE SMILE STUDIO ALL MEDICAL PROBLEMS OF WHICH I AM AWARE OF.
We feel it is important to share information with you on “how and why” our practice prides itself on spending quality time with each individual patient and provide quality dentistry at reasonable costs. We do this by having the office staff and patients acknowledge and abide by certain commitments
In most cases, we believe that all treatment begun should be completed. Incomplete treatment leads to problems, complications, further disease, and additional expenses. Therefore, if a plan is agreed upon and started, it, in most cases, should be completed. Rest assured that we would never move forward with treatment without your consent. We ask that you consent to discuss finances over the phone, email and mail. We are more than happy to send you or another dental provider your dental images for a $35 fee.
We reserve time for each patient in our practice and rarely keep patient waiting. An appointment written in our schedule with your name on it is a bond of trust that we will be here to serve your promptly and that you will be present for that appointment. Our answering machine does not accept appointments cancellations or changes. We must have mutual respect for each other’s time. We must charge a cancellation fee of $50 per hour of scheduled treatment if less than 72 hours’ notice of cancellation is not given.
We believe we have a responsibility to you to use our best professional care, skill and judgment in planning and delivering your dental treatment. We can only fulfill this mission through a bond of trust with you to pay for services. We will not move forward with treatment unless you are fully aware of fees and expected payment and then only with your consent. There will be a $35 fee for all returned or stopped checked after services are rendered. If you have an overdue balance and if we send your account to collections, we need to charge an interest rate of 10% from the date of delinquency (delinquency is a balance 30 days overdue from the date of billing) and if there was any courtesy adjustment, it will be reserved and full balance owed.
Our office does not diagnose, render treatment or establish fees according to any insurance tables or allowances. Our fees are based on the care, skill and judgment of the professionals delivering the services, and the cost of operating a dental office dedicated to excellence. Please remember that we work 100% for you, not your insurance company. Your dental plan may only cover charges for the least expensive results. We refuse to compromise our standards by offering anything less than the complete care that you deserve. We will file insurance claims as a courtesy to you. Please understand that YOU are ultimately responsible for any amounts not covered by your insurance plan. You give us the authorization assign all medical and dental payments from your insurance to us directly. You understand that you are financially responsible for all the charges not covered or paid by your insurance for whatever reason.
I have read and thoroughly understand the above statements.
- As of January 1, 2002, the Dental board of California now requires that we provide to our patients a copy of the Dental Material Fact Sheets (DMDS).
- As of April 14, 2003, the Health Insurance Portability and Accountability Act (HIPAA), we provide to our patients a copy of our Notice of Privacy Practices.
DENTAL SERVICE ARBITRATION AGREEMENT: The dentist whose name appears below agrees to provide to the undersigned patient dental, surgical and related health care services in consideration for the payment on a fee for service basis.
ARTICLE I It is understood that any dispute as to the 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 the submission to arbitration as provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
ARTICLE II Said agreement for arbitration as provided in Article I above shall apply to the dentist, agents, representatives and employees, successors in interest and staff of the dentist and patient “whether or not a minor” his heirs-at-law, personal representatives and any claim in tort, contract or otherwise the other of the demand for arbitration of any controversy, the parties to the controversy shall each appoint an arbitrator and give notice of such appointment to the other. Within a reasonable time after notice has been given, the two arbitrators so shall hold a hearing within a reasonable time after notice has been given, the two arbitrators so selected shall select a natural arbitrator and give notice of the selection thereof to the parties. The arbitrators shall hold a hearing within a reasonable time of the date of the notice of the selection of the neutral arbitrator, all notices or other papers required to be served shall be served by U.S. mail.
ARTICLE III The dentist named below agrees only to provide such services as in his/her opinion are reasonable necessary and appropriate. Should patient for reasons personal to him himself refuse to accept the procedures medicines or courses of treatment recommended by the dentist, and if the dentist believes that no professional alternative exists, and after being advised that the patient still refuses to follow the recommended treatment or procedure, the patient shall be given no further treatment and the dentist shall have no responsibility to the patient. This agreement may be terminated only if written notice is given by the patient within 30 days from the date the patient executes this agreement and if no such notice is given, the agreement herein concerning arbitration shall be binding and compulsory.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE AN ISSUE OF DENTAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING AWAY RIGHT TO A JURY OR COURT TRAIL.