Patient Registration

Status *

First Name *

Middle Initial

Last Name *

Social Security Number 🛈

Date of birth * +

Age

Sex *

M

F

Street Address *

Apt#

City *

State *

Zip Code *

Home Phone

Work Phone

Cell Phone

E-mail

Employer

Address

Occupation

Are you a student? *

Yes

No

Full Time: *

Yes

No

School *

Full time college students using parent's insurance plan must provide proof of full-time student status.

Name of parent or legal guardian accompanying minor:

First Name *

Last Name *

Date of birth * +

Social Security Number 🛈

DL#

State *

Address *

Apt#

City *

State *

Zip Code *

Relationship to minor *

Home Phone

Cell Phone

Employer

Address

Work Phone

For children under 18 years of age, the legal guardian or parent accompanying the child to this appointment is deemed the responsible party for the payment on this account.

Emergency contact

First Name *

Last Name *

Phone *

Relationship *

Name of a friend or relative not living with:

First Name *

Last Name *

Relationship *

Phone *

Referred by

First Name *

Last Name *

Patient's Dentist *

Completion

ASSIGNMENT AND RELEASE: I hereby authorize payment to Dr. Tannaz Malekzadeh, D.M.D.,/ Malek Periodontics for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the use of this signature on all insurance submissions. I further authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf, should the need arise.

(Please initial) *

Financial Policy (for all patients): The following describes our Financial Policy. Our office is committed to providing you with the best possible care. Your understanding of our financial policy is an essential element of your care and service. If you have any questions regarding any aspect of our policy, please feel free to present your question to any of our team members.

Payment for services is due at the time services are rendered. We accept cash, debit card, and for your convenience Visa, MasterCard, American Express, Discover and 3rd party financing through Care Credit.

(Please initial) *

Insurance Policy and Assignment of Benefits (for patients with dental insurance only): As a service to our patients we are happy to file the forms necessary to see that you receive the full benefits of your coverage. Because your insurance policy is a contract between you, your employer and the insurance company, it is your responsibility to make sure we have accurate and up to date insurance carrier information, restrictions of your policy and billing information. Failure to provide us with insurance information at the time of service will result in NO CLAIM FILED. Every effort will be made to closely estimate your co-payments and deductibles which are due at the time of service. If an insurance company has not paid within 60 days, any unpaid balance is due and payable in full from you. Services which are not covered by your insurance are your responsibility. Payment in advance may be required for certain treatment in order to reserve chair time and fund dental laboratory fees.

(Please initial) *

If there is insurance, the balance not estimated and collected in advance is due wihin 60 days from the date of service or when insurance pays, whichever is first. Pursuant to the Federal Consumer Credit Protection Act, we disclose that no interest charge will be applied if this agreement is adhered to. If the terms of this agreement are not met, interest charges of 1.5% per month is to be adhered to the remaining balance (18% per year) in addition to the entire balance becoming due. 1 also understand that upon failure to pay for services rendered, my account may be sent to collections.

(Please initial) *

Appointment Policy (for all patients): We will work hard to accommodate appointments that fit your schedule and dental needs. Due to limited availability in the schedule, high demand for requests and the effort we put forth to accommodate your needs, we require a 24-hour advance notice to cancel or reschedule any appointment. Failure to do so will result in your account being charged the FULL AMOUNT of the treatment. Habitual missed appointments are grounds for dismissal from the practice.

All minor patients must be accompanied by an adult (parent or legal guardian). The adult accompanying the minor is required to pay in accordance with our policies. We neither accept third party assignments nor do we recognize or enforce the terms of divorce or child support decrees.

(Please initial)

*

HIPPA NOTICE: You have the right to read our Notice of Privacy Practices before you decide to initial this section. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices to follow federal/state guidelines. You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to our office. Please understand that revocation will NOT affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent. Full HIPPA notice available by request.

(Please initial) *

I authorize the doctors or staff to discuss my care and/or treatment with my primary emergency contact listed above. *

Yes

No

(Please initial) *

Methods of Payment Accepted: Cash, Debit, Credit, Money Order, Care Credit.

I will be paying today by: *

Signature (Parent or guardian, if patient is a minor) *

clear

Date * +