New Patient Registration New Patient Registration

Patient Registration Form

Dental Crowns Bridges Lake Elsinore, CA
Policy holder Responsible party

Responsible Party (if someone other than the patient)

Patient Information

Secondary Insurance policy holder
I would like to received correspondences via email
SECTION 2
SECTION 3
Referral Source : How did you hear about us:

Primary Insurance Information

Secondary Insurance Information


Office Policy

Aava Dental

Dear Patients,

Thank you for choosing Aava Dental as your family dental provider. We look forward to providing you high quality dental care at an affordable price.

When scheduling your appointments, we are making a commitment to you. Please remember that we have reserved a special time for you. If you find a need to reschedule your appointment, we ask for a minimum of 48 hour notice. Failed appointments and canceled appointment without 48 hours are subject to an $85.00 fee.

Checks returned for insufficient funds are subject to a $35.00 fee. This fee is enforced to cover our bank charges. Please let us know if special arrangements must be made.

Patient portion is due at time of services. Please bring your co-payment with you.

We bill your insurance as a courtesy to you. If any amounts are denied or not covered, the balance owing is your responsibility. Your estimated patient portion for services is based upon the information provided by your insurance company, and is expected on the day treatment is rendered. Please ask for an estimated, if one has already been given to you.

I declare that I am not a recipient of the state assisted insurance, including but not limited to, California Department of Health Services. If I am, I am fully aware that the office will not bill CDHS nor are they provider for CDHS.

Patient acknowledges in consideration for dental services to be rendered any outstanding debt to our office will not be included in any bankruptcy petition.

Thank you again for your understanding and care with helping to keep our facilities safe and clean and helping us provides you with the best possible dental care.

Patient Signature:

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No



Women:
Yes    No

Yes    No

Yes    No

Are you allergic to any of the following?
Other If yes, please explain:
Do you have, or have you had, any of the following?
Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

If yes, please explain:
Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN
Date

INFORMED CONSENT FOR DENTAL TREATMENT

A.     IDENTIFICATION


B.     STATEMENT OF REQUEST Please initial beside the following lines. By initialing, you signify you fully understand the statement and/or our office policies


FOR ALL NEW AND RECALL PATIENTS: Oral Evaluations, Prophylaxis/Cleaning, Radiographs.

I further request and authorize the taking of oral dental x-rays and the use of such anesthetics as may be considered necessary and/ or advisable by the doctor responsible for my treatment.
I fully disclosed all health problems, including but not limited to: heart conditions, high/low blood pressure, diabetes, need for antibiotics prior to dental treatment (due to
prosthetic valves, joints or heart conditions), medications taken/prescribed, bleeding problems, and allergies.


If you are receiving dental treatment other than an exam, dental cleaning and radiographs, please read and initial beside the Description of Treatment/Procedure(s):


For Oral Surgery: The extraction of a tooth is an irreversible process and whether routine or difficult, it is a surgical procedure. In any surgery, there are some risks. These risks include, but are not limited to, the possibility of pain or discomfort during and after the following treatment, swelling, infection, bruising, dry socket (due to dislodged blood clot), bleeding, injury to adjacent teeth (especially with large fillings, decay or crowns) and surrounding tissue, TMJ disorder, limited jaw opening of or displacement of a tooth or portion thereof into the sinus (especially with upper back teeth) or other anatomic location requiring additional surgery (and possible referral to Oral Surgeon) to close the opening or recover the tooth structure, temporary or permanent numbness, jaw fracture and allergic reactions. In addition, the decision to leave a small piece of root in the jaw when its removal would require extensive surgery may be necessary. To avoid injury to vital structures such as nerves or the sinus, small root tips may be left in place. Sharp ridges, or bone splinters may form later at the edge of the socket and may require another surgery to smooth or remove. The usual and most frequent risks and complications occurring from the planned treatment have been explained to me and by signing this form, I consent to the extraction of the above tooth/teeth


For Dentures and Partial Dentures: I realize that full or partial dentures are artificial and the problems of wearing these appliances have been explained to me (including, but not limited to, looseness, soreness, and possible breakage). I realize the final opportunity to make changes in my new dentures (including shape, size, placement and color of the teeth) will be the "teeth in wax" try-in visit. I understand the appliance may need to be relined 3-15 months after fabrication and the cost for this is not included in the initial denture. There may be additional charges for denture/partial adjustments in the future


For Crowns and Bridges: I understand it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand I will be wearing temporary crowns and will ensure that they are kept on the tooth until the definite crown/bridge is cemented. I will verify the shape, color and size at the first appointment as the crown will be ready to cement at the following appointment. Endodontic procedures (root canals) are sometimes necessary after the preparation for the crown; root canals are a separate procedure and you may need to see a specialist if a root canal is needed. For implant crowns, we are not responsible for the successful placement and guarantee of the implant as we did not perform the implant placement.


For Endodontic Treatment (Root Canal): I realize there is no guarantee that root canal treatment will save my tooth, and that a complication can occur from the treatment that may necessitate the extraction of the tooth. Occasionally metal objects are cemented in the tooth or extend through the root, which may/may not necessarily affect the success of the treatment. I understand there is considerable risk of instrument separation during root canal treatment in which referral to an Endodontist may be necessary to evaluate the situation, complete root canal treatment and /or perform surgical procedures to increase the root canal success. I understand that occasionally additional surgical procedures may be necessary following root canal treatment, root canals may have to be retreated, referral to an Endodontist (Ex:complicated root canal anatomy, inability to locate canals, calcified canals) may be necessary. If a tooth fracture is present, it may not be visually detected but may lead to the loss of the tooth, even after a root canal is performed.


For Conscious Sedation: I understand I am not to drive after taking medications for dental anxiety. In addition, I will not operate machinery for the remainder of the day. I am not allergic to benzodiazepines (Valium, Triazolam, Versed, Ativan, etc.), pregnant or breast feeding, nor do I have liver or kidney disease. I have not consumed alcoholic beverages in the past 12 hours, nor have I used illicit drugs. Side effects may include light-headedness, headache, dizziness, visual disturbances, amnesia, and nausea. In some people, such as smokers, oral sedative may not work as desired. On the way home, your seat in the car should be in the reclined position. When at home, lie down with your head slightly elevated. Someone should stay with you for the next several hours due to possible disorientation and possible injury from falling.


During the course of treatment, complications may arise that may necessitate additional procedures or alter the proposed course of treatment. Such complications may include, but are not limited to, the need for a root canal and or extraction. I acknowledge the practice of dentistry is not an exact science and offers no guarantees. When administering anesthetic, there is a rare but unavoidable risk of possible nerve damage, paralysis and/or dysesthesia. These complications may be temporary or permanent.

  C.   SIGNATURES - : I have had sufficient opportunity to discuss the treatment plan, the benefits to be reasonably expected from this treatment, as well as the alternative approaches, including no treatment. All of my questions have been answered to my satisfaction, and I consent to the treatment and procedures prescribed. I confirm I have read this form or it was read to me.


COUNSELING DENTIST/PROFESSIONAL: I have counseled this patient as to the nature of the proposed procedure(s), attendant risk involved, and expected results, as described above.


Signature of Counseling Dentist/Professional Date and Time

PATIENT: I understand the nature of the proposed procedure(s), attendant risks involved, and expected results, described above.

Signature of Patient or Legal Guardian Date and Time
Signature of Provider Date and Time

AAVA DENTAL
Acknowledgement of Receipt of Statement of Policy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Aava Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties to this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Aava Dental reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices changes, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosure described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

Yes    No

Yes    No

Yes    No


Name of Patient or Responsible Party
Signature of Patient or Responsible Party
Date
Description of Responsible Party’s Authority

OFFICE USE ONLY
RECORD OF ACKNOWLEDGEMENT NOT OBTAINED

Yes    No

Date Provided:
Reason for Denial:
Need more time to review statement of Privacy Practices.
Wanted to consult with another person, before signing.
Unable to sign.
Reason not given.
Other (explain):

AAVA DENTAL’S PATIENT-DENTIST ARBITRATION AGREEMENT

Article 1: It is understood that any dispute as to dental malpractice, that is to whether any dental services rendered under this contract were unnecessary, or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or report to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.



Initials of Patient or
Patient’s Legal Representative



Article 2: I understand and agree that this Arbitration Agreement binds me and anyone else who may have a claim arising out of or related to all treatment or services provided by the dentist, including any spouse or heirs of the Patient and any children, whether born or unborn at the time of occurrence of any claim. This includes, but is not limited to, any dispute arising from tort, contract, negligence or otherwise for monetary damage, including, without limitation, suits for loss of consortium, wrongful death, emotional distress or punitive damages or actions brought on behalf of Patient by third parties, shall be submitted to binding arbitration and not a lawsuit. I further understand and agree that if I sign this Agreement on behalf of some other person for whom I have responsibility, then, in addition to myself, such person(s) will also be bound by this Agreement, along with anyone else who may have a claim arising out of the treatment or services rendered to that person. I also understand and agree that this Agreement relate to the claims against the dentist and any consenting substitute dentist, as well as the dentist’s partners, associates, associations, corporation or partnerships, and the employees, agents, and estates of any of them. I also hereby consent to the intervention or joinder in the arbitration proceeding of all parties relevant to the full and complete settlement of any dispute arbitrated under this Agreement.



Initials of Patient or
Patient’s Legal Representative



Article 3: The arbitrator shall have the authority to award any remedy or relief that a court of the state of California could order or grant, but no other remedy or relief. The award must be limited to the relief available to a California state court and under California law for the cause(s) of action at issue in arbitration. However, each party shall bear its own costs, expenses, legal fees, witness expenses, and 50% of the arbitrator’s fees and such expenses may not be awarded against the opposing party. The provisions of California law applicable to healthcare providers shall apply including, but not limited to, California Code of Civil Procedure sections 667.7 and 425.13, and California Civil Code sections 3333.1 and 3333.2. I agree that the arbitrators have the same immunity from civil liability as that of a judicial officer when acting in the capacity of arbitrator under this Agreement. This immunity shall supplement, not supplant, any other applicable statutory or common law.



Article 4: I UNDERSTAND THAT I DO NOT HAVE TO SIGN THIS AGREEMENT TO RECEIVE THE DENTAL SERVICES, AND THAT IF I DO SIGN THIS AGREEMENT AND CHANGE MY MIND WITHIN 5 DAYS OF TODAY, THEN I MAY CANCEL THIS AGREEMENT BY GIVING WRITTEN NOTICE TO THE UNDERSIGNED DENTIST WITHIN 5 DAYS OF THE DATE OF MY SIGNATURE BELOW STATING THAT I WANT TO WITHDRAW FROM THIS ARBITRATION AGREEMENT.



Article 5: I understand that each dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist other than the treating dentist is responsible for my dental care. I understand that Aava Dental, its past, present, or future owners, shareholders, officers, board of directors, or employees are not responsible for my dental care.



Initials of Patient or
Patient’s Legal Representative

Article 6: I have read and understood this Agreement. I understand that in the case of a pregnant woman, the term “patient” as used herein means both the mother and the mother’s expected child or children.
By initialing below, Patient intends and acknowledges this Arbitration Agreement to cover claims arising before the date it is signed. This Arbitration Agreement is effective as of the date of this provision of the first care or service of any kind, whichever is earlier. Patient acknowledges to have received a signed copy of this Agreement.



Initials of Patient or
Patient’s Legal Representative

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF DENTAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE OF THIS CONTRACT.

(Patient, Parent, Guardian or Legally Authorized Representative of Patient)

Dated:

If signed by other than patient, indicate relationship:

The treating Dentist understands that he/she is the only person who is responsible for the dental care of the patient. The Treating Dentist agrees to defend, indemnify and hold Aava Dental harmless against any and all claims, lawsuit, or actions by Patient against Aava Dental arising out of the treatment rendered by the treating Dentist and/or the assistants working with the treating Dentist.

Dentist’s Agreement to Arbitrate: In consideration of the foregoing execution of this Patient-Dentist Arbitration Agreement, I likewise agree to be bound by the terms set forth in this Agreement and in the rules specified in Article 3 above.

Dentist or Duly-Authorized Representative

Dated:

Title

Aava Dental

I have the understanding that my dental provider maybe out5of5network and my dental insurance may forward me the check(s) for the procedure(s) that was performed by Aava Dental.

I am informed that upon receipt of this check, I am to sign the back of the check (“endorse the check”) and submit (mail/hand deliver) it to the Aava Dental branch from which I received the treatment.

If the check(s) received from the insurance company does not return to Aava dental within 2 weeks, Aava Dental is authorized to send my balance to the collection agency.

Yo tengo entendido que mi seguro dental puede no estar en conexión con Aava Dental, y mi seguro puede enviarme el cheque a mí en vez de enviarlo a mi proveedor dental.

Estoy informado que al recibo del dicho cheque, tengo que firmar (endosar el cheque) and entregar (mandar o llevar a mano) lo a la oficina donde habia recibido tratamiento.

Si yo recibo dicho cheque, yo endosaré el cheque al reverso y lo enviare a la oficina de Aava Dental en donde he recibido tratamiento en dos semanas o Aava Dental esta autorizado a mandar su balanca a una agencia de collecion.


Patient name Nombre Del Paciente



Date Fecha


Patient signature Firma Del paciente