Hooman Lohrasbi D.D.S.

2380 Firewheel Parkway, Suite 900, Garland, TX 75040

469-587-6364

Welcome

Patient Information

Date:
SS/HIC/Patient ID #:
Patient:
Address:
City:
State:
Zip:
E‐mail:
Sex:
Age:
Birth Date:
Occupation:
Patient Employer/School:
Employer/School Address:
Employer/School Phone:
Spouse's Name:
BirthDate:
SS#:
Spouse's Employer:
Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?
Relationship to Patient:
Insurance Co.:
Group #:
Is patient covered by additional insurance?
Subscriber's Name:
Birthdate:
SS#:
Relationship to Patient:
Insurance Co.:
Group #:

ASSIGNMENT AND RELEASE

I certify that I. and/or my dependent(s), have insurance coverage with and assign directly to Dr. 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 doctor 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 or the benefits payable for related services This consent will end when my current treatment plan is completed or one year from the dale signed below.



Signature of Patient, Parent Guardian or Personal Representative

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Name of Patient, Parent, Guardian or Personal Representative:
Date:
Relationship to Patient:

Phone Numbers

Home:
Work:
Ext:
Cell Phone:
Spouse's Work:
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)
Name:
Relationship:
Home Phone:
Work Phone:

Dental History

Reason for today's visit:
Former Dentist:
City/State:
Date of last dental visit:
Date of last dental x-rays:

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

Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe. or cigar smoking
Clicking or popping jaw
Dry Mouth
Fingernail biting
Food collecting between teeth
Foreign objects
Grindteeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth
How often do you floss?
How often do you brush?

Health History

Physician's Name
Date of last visit:

Have you ever taken any of the group of drugs collectively referred to as 'fen-phenr These include combinations of lonimin. Adipex. Fastin (brand names of phentermine), Pondimin (fenfluramin e) and Redux (dexfenfluramine).  

Place a mark on "yes" or "no" to indicate if you have had any of the following.

AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back problems
Bleeding abnormally, with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis
Type
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcers
Venereal Disease
Weight Loss, unexplained

Do you wear contact lenses?

WOMEN

Are you pregnant?
Due date
Are you nursing ?
Taking birth control pills?

Medication

List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name
Phone

Allergies

Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?
For what conditions?
Are you taking any new medications?
If so, what?

Patient's Signature

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Date:

Doctor's Signature

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Date:

Has there been any change in your health since your last dental appointment?
For what conditions?
Are you taking any new medications?
If so, what?

Patient's Signature

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Date:

Doctor's Signature

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Date:

HIPAA Patient Consent Form


I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
  • Obtaining payment from third party payers (e.g. my insurance ompany);
  • The day-to-day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of the notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the dare I revoke this consent is not affected.


Patient Name:
Relationship to Patient:
E‐mail:
Phone:

Signature

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Signed Date:

Financial Agreement


Thank you for choosing us to provide your dental care We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff

DENTAL INSURANCE: As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following:

  • You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim.
  • Your insurance policy is a contract between you. your employer and the insurance company We are NOT a party to that contract. Our relationship is with you and not your insurance company
  • You are responsible for our fees and not what your insurance company allows or considers "usual, customary and reasonable" all of which vary from one company to another.
  • Although we may estimate your insurance benefits we are not responsible for their accuracy Knowledge of benefits as well as benefit amounts, limitations, exclusions. waiting periods. etc is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate
  • All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for noncovered services, along with deductibles and copayments are due at the time of treatment

PAYMENT POLICY

  1. We accept cash, personal checks, debit cards, Visa, MasterCard and Discover
  2. After dental insurance has paid its portion. a statement is sent to the mailing address on record, for the remaining balance. Payment is expected within 30 days of the statement date, to avoid finance charges.
  3. We do not file claims for medical insurance or more than one dental insurance company per patient.

PATIENTS WITHOUT INSURANCE COVERAGE: We provide written estimate of fees. and payment is expected at each visit for services rendered.

BROKEN OR MISSED APPOINTMENTS: Appointments not kept or changed with less than 48 hours notice are considered broken. Broken appointments will be rescheduled during the morning hours and subject to additional fees Broken appointments prevent others from receiving the dental care they deserve We take them seriously so please be considerate and inform us in advance if you need to change: your appointment.

FEE FOR MISSED APPOINTMENT IF 48-HOUR NOTICE NOT GIVEN: Each time a patient misses an appointment without providing proper notice. another patient loses an opportunity to receive timely care. If you are unable to keep your appointment, we respectfully ask that you notify our clinic at least 48 hours in advance. Failure to cancel/reschedule an appointment that you do not attend will be considered a missed appointment or no show.

Due to high patient demand, and limited availability of appointments we have instituted a $50 no show fee for weekdays and $75 for appointments made for either Saturdays or for the day before or the day after Holidays*. As of July 1st, 2013, you must give 48 hour advanced notice to cancel/reschedule appointments. Failure to do so will result in a $50/$75 fee charged to your account. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept.

MINOR PATIENTS: The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit.

RETURNED CHECKS: A $30.00 charge applies when a check is returned by the bank.

FINANCE CHARGES AND COLLECTION FEES: Finance charges will be applied to all balances not paid within 30 days of the monthly billing date. A late charge of 1.5% on the balance then unpaid and owed will be assessed each month until paid. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

RECORDS AND REIMBURSEMENTS: Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs.

We understand temporary financial problems may affect timely payment of your balance. In those situations we encourage you to communicate any such problems immediately so we may assist you in the management of your account.

CONSENT & AUTHORIZATION: I authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understood this document in its entirety, outlining office policies and financial policies of Parkway Dental Care. Without any reservations, I agree to abide by the policies outlined herein.


Patient Name:
Parent/Guardian's Name:
E‐mail:
Phone:

Signature of Patient

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Date:

Signature of Parent or Guardian

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Date:

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