Spouse or Responsible Party Information
The following is for:    the patient’s spouse   the person responsible for payment
Name
  Male Female Married Single Child Other
Social Security Number                                           Birth Date:                                
Phone    Work   Ext:    Best time to call
Address
Employment Information
The following is for:    the patient’s spouse   the person responsible for payment
Employer   Occupation  
Address
Employer   Occupation  
Address
Insurance Information
Primary
Name of Insured:   Is insured a patient?    Yes No
Insured’s Birth Date:                            ID# Group#
Insured’s Address:
Insured’s Employer Name  
Address
Patient’s relationship to insured      Self   Spouse   Child   Other
Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s accounts.
However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½ % per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

Dr. Athari’s dental corporation has invested significant financial and marketing resources in developing the practice. The office of Dr. Athari does not attempt to prevent a client from posting commentary about him or the office or its practice or expertise on web pages or blogs. In consideration for services and noted protection, if the client prepares such commentary for publication on web pages about the Firm, the client assigns all intellectual property rights, including copyrights, to the Firm for any statements made by client about the Firm and any written, pictorial, and/or electronic response. The client acknowledges the effectiveness of this provision at the time of execution of this agreement and at the time of commentary.

First non wisdom tooth extraction only, non insurance patients only, does not include exam and x-ray, does not include nitrous oxide sedation, does not include bone grafts or sinus closures or bone removal (alveoloplasty), does not include laser or any other treatment that has its specific ADA dental code, other limitations may apply, treatment limitations are at the discretion of the doctors on duty and he or she may elect to refer to an oral surgeon, does not apply for non business hours or public holidays, there will be extra fees for those occasions, other than nitrous oxide sedation no other way of sedation such as IV sedation will be performed at this facility. Other future promotions and prices advertised must have exam and x-ray prior to that treatment and those promotions do not include the exam and x-ray, the $500 crown is limited to two per patient and does not include build-up, laser or any other treatment that has a specific ADA dental code, does not include gold crowns and porcelain fused to gold, it is porcelain fused to metal only, does not include ceramic or full porcelain crowns or veneers.

$100 any silver filling, does not include liners, bases, or desensitizers,  does not include gold,white, composite, or ceramic type fillings.

There will be an office visit charge of $15 to all patients. This includes the sterilization fee. This fee is waived for your first visit.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

In the event I fail to pay for any part of the services rendered, I understand that I will be sent to a collection agency and will be required to pay all collection and legal fees as well as all court costs.

I have read the above conditions of treatment and payment and agree to their content.
 
                                                                                                                                                      
Signature of patient, parent or guardian                        Date                           Relationship to Patient:
 
                                                                                                                                                      
Signature of patient, parent or guardian                        Date                           Relationship to Patient:
 
 
Access Code Case Sensitive