Patient Form Old


This year marks the beginning of many exciting changes in my office in my effort to improve service and quality of care for you so that you can regain and maintain your health as quickly, efficiently, and inexpensively as possible. I have a purpose - and that purpose is to get sick people well and to prevent the well from getting sick. I also have a personal, professional, and ethical responsibility to care for your health to the best of my ability. Missed appointments and failure to comply with recommended treatment schedules and/or procedures prevent me from achieving my goal of optimum health for you. If you cannot keep your appointments and adhere to my treatment recommendations, I will not be able to continue treating you in good conscience. Therefore, the following policies must be agreed upon:

1. No-shows are not acceptable. Failure to make an appointment not only compromises your health but inconveniences other patients who may have requested an office visit during your scheduled appointment. If you cannot make an appointment (except in the case of an emergency) you are expected to call within 48 hours of your appointment to reschedule. There is a $50.00 fee for all no-show appointments per hour and this fee is not covered by insurance. This money will be matched by CLIENT NAME and donated to St. Jude’s Children’s Hospital.

2. Timeliness is required. We will see you on time and get you out on time unless there is an emergency. We request that you be on time for your visits. If you are more than 10 minutes late, you may have to reschedule your appointment.

3. Cleanliness and infection control are of the utmost importance. We have the - latest sterilization technology and disinfect each treatment room after every patient. This is another important reason we demand timeliness of you and ourselves. We request that you brush your teeth prior to being seated in a treatment room. Toothbrushes, paste, mouth rinse, and floss will be provided for you if needed.

4. If you miss an appointment you must make it up. It is critical to your health to do so to avoid setbacks in the care and maintenance of your teeth and gums.

5. Insurance: Treatment recommendations are based on your health not on your insurance or lack thereof. If you have insurance it is your responsibility to be aware of what your benefits are. Remember insurance companies are not concerned about your health or well being - we are. We will provide you with an estimate of benefits; however you are fully responsible for any treatment performed. Your benefits are a contract between you and your insurance company. We cannot be responsible for what your insurance will or will not cover.

6. We run a Zero Balance office. We expect payment in full prior to or at the time treatment is provided. We have several financial options available for all of our patients. Please speak to (designated team member) if you have any questions.

7. In order to schedule an appointment with DR. Arash Vahid, we require 50% of the total patient out-of-pocket expense as a deposit and a signed financial agreement.

8. Our policy is to make your experience in our office an exceptional one. When we succeed, we would appreciate you telling your family and friends about our office.

9. Upsets: It is our company policy to ensure the complete satisfaction of all of our patients with the service and care they receive at our office. However, it is possible on occasion that there may be a misunderstanding or miscommunication between you and our office. We will do everything in our power to make things right by you should an upset occur provided you bring it to our attention in an appropriate, cordial manner and at a time that we can give the matter the proper attention it deserves for effective resolution. You can expect that my staff will treat you with the same professional demeanor and efficiency, as you would expect from them. Pl·ease see our office manager to resolve immediately any upsets you may have with my office or one of my team.

10. Emergencies: It is our goal to eliminate all of the potential dental emergencies you may have by providing care for you before it becomes a problem. In the rare instance that you do have an emergency we want you to be assured that we will take care of you. In order to do this we would like to define what a true emergency is. Swelling, bleeding, severe pain that has kept you up at night or requires medication, or a restoration in a visible area that falls out are all considered emergencies. If you have any of these symptoms we ask that you call us right away. We will provide you with the next available emergency appointment. We do set aside time each day for emergencies. I greatly appreciate your cooperation. Yours in Health, Dr. Arash Vahid

Patient Information

Dental Insurance


I certify that I, and/or my dependent(s) have insurance coverage with

and assign directly to Name of Insurance company(ies)

Dr. Arash Vahid

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 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 payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Please print name of Patient, Parent, Guardian, or Personal Representative

Phone Numbers

IN CASE OF EMERGENCY, CONTACT (Specify someone who doesn’t live in your household)

Dental History

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

Dental Registration and History

Health History

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




Updates (To be filled in at future appointments)

Patient acknowledgments of Receipt of Privacy Practices Notice

, hereby acknowledge that I have reviewed and received a copy of this office’s Notice of Privacy Practices explaining:

• How this office will use and disclose my protected health information.
• My privacy rights with regard to my protected health information.
• This office’s obligations concerning the use and disclosure of my protected health information.
I understand that Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices.
I also understand that if I have any question or complaints, I may contact:

You may also contact the secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures.
Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

Patient or Personal Representative

For Office Use Only

receipt of our Notice of Privacy Practices. In spite of these efforts, our office has been unable to obtain a signed acknowledgment of receipt
for the following reasons (Check all that apply):

Communication barriers prohibited obtaining an acknowledgment.

An emergency situation prevented us from obtaining an acknowledgment.


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