CONFIDENTIAL PATIENT INFORMATION
Aesthetic Dentistry
Vahid Varasteh, D.M.D.
Nicholas Marinakis, D.D.S.
Mina Kalali, D.M.D (Children’s Specialist)
DATE___________
PERSONAL INFORMATION
Name:__________________________________E-Mail____________________________
Address___________________________________________________________________
STREET
CITY
STATE
ZIP
Telephone: Home:_____________Business_______________Cell____________________
Birthdate:_____________Sex:_____Marital Status:_______Spouse Name______________
Occupation:_____________________________Referred by:_________________________
Reason for visit________________________________________________________________________
Last Dental Visit____________Seen by:___________________________________________________
NAME
ADDRESS
Personal Physician:____________________________________Phone_________________
Pharmacy Name:_____________________________________Phone__________________
HEALTH INFORMATION
YES NO
1. Have you been hospitalized within the past 2 years? For what?______________
2. Are you currently being treated by a physician? For what?_________________
3. Are you currently taking any medicines or drugs? What? ___________________
4. Have you ever received counseling for excessive use of alcohol
and/or prescription drugs?
5.Are you allergic to any drugs? What?___________________________________
6. Are you allergic to any metals? What?__________________________________
7. Have you ever had a skin rash or other reaction? __________________________
to metal jewelry? To what? __________________________________________
8. Do you bleed excessively upon injury?__________________________________
9. Are you pregnant?___________________________________________________
PLEASE CONTINUE TO OTHER SIDE
CIRCLE ANY OF THE FOLLOWING CONDITIONS WHICH YOU HAVE HAD
A. AIDS
B. Arthritis
C. Asthma
D. Cancer
E. Diabetes
F. Epilepsy
G. Glaucoma
H. Heart Murmur
I. Heart Problem
J. Hepatitis
K. High Blood Pressure
L. Jaundice
M. Kidney Problems
N. Low Blood Pressure
O. Nervous Breakdown
P. Psychiatric Therapy
P. Rheumatic Fever
Q. Sexually Transmitted Diseases
R. Stroke
S. Tuberculosis
T. Other Diseases
If you circled either I or T describe condition
_______________________________________
_________________________________
_______________________________________
PERSON RESPONSIBLE FOR ACCOUNT
Name:________________________Relationship_____________SS#__________________
Address:___________________________________________________________________
STREET
CITY
STATE
ZIP
Telephone: Home: ________________Business___________________________________
DENTAL INSURANCE INFORMATION
Primary Insurance Co.: _______________________________________________________
NAME
ADDRESS
Employee:____________________________Relationship:_____________ID#____________
Employer: _____________________________________Group#_______________________
Secondary Insurance Co._______________________________________________________
NAME
ADDRESS
Employee:__________________________Relationship______________SS#_____________
Employer:_______________________________________Policy #_____________________
I understand that payment is my obligation regardless of insurance or any other third party
involvement. There will be a charge for appointments cancelled or broken without 24 hrs. notice.
Signature:________________________________________________Date:_______________
PERSON TO BE CONTACTED IN AN EMERGENCY
_______________________________________________________________________________
NAME
ADDRESS
PHONE#
Mission Statement:
“OUR MISSION IS TO IMPROVE THE LIVES OF OUR PATIENTS
THROUGH DEDICATION AND COMMITMENT TO EXCELLENCE IN
DENTISTRY.”
Aesthetic Dentistry
Consent Form
I hereby authorize the Doctors at Aesthetic Dentistry to take any necessary x-rays, study
models, images, or any other diagnostic aids needed to make a thorough diagnoses of my
dental needs.
I also authorize the Doctors at Aesthetic Dentistry to perform any necessary treatment,
prescribe medications and therapy that may be indicated after being discussed with me.
I understand that I will be responsible for the cost associated with services that have been
provided for me. If applicable, Aesthetic Dentistry will bill my dental insurance company.
I will remain responsible for any co-payments or services not covered at the time of my
visit unless other financial arrangements have been made. I understand that any unpaid
balance will be subject to finance charges.
Name _____________________________________ Date____________________
(Signature)
Aesthetic Dentistry, PC – 240 Main Street - North Reading MA 01864 – (978) 664-5901
Dental Office Policy
Your HIPAA Practices
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMAION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH
INFORMATION IS IMPORTANT TO US.
________________________________________________________________________________________________________
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to
give you this notice about our privacy practices, our legal duties, and your rights conferring your health information. We must
follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 08/01/2008, and will
remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time,
provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and
the new terms of our notice effective for all health information that we maintain, including health information we created or
received before we made the changes. Before we make a significant change in our privacy practice, we will change this notice
and make the new notice available upon request. You may request a copy of our notice at any time. For more information about
our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this
notice.
________________________________________________________________________________________________________
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For Example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to
you.
Payment: We may use or disclose your health information electronically or by mail to obtain payment from health plans and
insures for the care that we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of
healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation,
certification, licensing, or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may
give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your
authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information
for any reason except those described in this notice.
Persons Involved In Care: We may use or disclose health information to notify or assist in the notification of (including
identifying or locating) a family member, your personal representative or another person responsible for your care, of your
location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will
provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency
circumstances, we will disclose health information based on a determination using our professional judgement disclosing only
health information that is directly relevant person’s involvement in your healthcare. We will also use our professional judgment
and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up
filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written
authorization.
Required by Law: We may use or disclose your health information if, by law, we are required to do so.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as
phone calls, voicemail messages, text, email, postcards, or letters).
Electronic Transfers: We may use or disclose your health information electronically if in relations to obtain payment, referrals
for another health care provider or unless otherwise stated with your permission.
Aesthetic Dentistry, PC – 240 Main Street - North Reading MA 01864 – (978) 664-5901
Dental Office Policy – Your HIPAA Practices – Notice of Privacy Practices – Our Legal Duty – Uses and
Disclosures of Health Information
I,__________________________________________________________have read and agree to the above
HIPAA Privacy Policy.
(Print name)
Signature:___________________________________________________________Date:_______________
I have received a copy of Aesthetic Dentistry’s Office Policy and HIPAA Practices
Personal Health Information Release Form
(HIPAA Release Form)
[ ] I authorize the release of any and all information including the diagnosis, financial and dental records;
examination rendered to me and claims information. This information may be released to:
[ ]
Spouse_______________________________________D.O.B._____________Phone__________________
[ ]
Child(ren____________________________________D.O.B.______________Phone__________________
[ ]
Other_______________________________________D.O.B._____________Phone___________________
[ ] Information is not to be released to anyone.
Signature:_________________________________________________________
Date:____________________________
This Release of Information will remain in effect until terminated by me in writing.
Aesthetic Dentistry, P.C.
Financial Policy
*PAYMENT IS DUE AT THE TIME SERVCIES ARE RENDERED*
In order to provide services which are financially manageable to our patients, we offer the following options
for payment:
Cash, Check or Credit Card, (Visa, MC, AMEX & Discover)
Care Credit
Monthly Payment Plan
Insurance Submittals
We will be happy to submit charges to your insurance carrier with advance notice of coverage. If we are
unable to verify insurance coverage prior to your appointment we will gladly provide a paid receipt for
direct reimbursement. When submitting insurance, the estimated uncovered portion is due on the day of
treatment. Any balance not covered by your insurance company is your responsibility. All insurance
balances over 60 days will be transferred to your account at which time we will notify you of your
responsibility for payment.
YOUR INSURANCE COVERAGE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE
CARRIER. IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE COVERAGE. WE WILL
DO OUR BEST TO ACCURATLY ESTIMATE YOUR OUT OF POCKET EXPENSE, ALTHOUGH
YOU ARE ULTIMATELY RESPONSBILE FOR ALL TREATMENT CHARGES.
The parent that accompanies a minor to a dental visit is the person responsible for payment.
In order for the dental laboratory to fabricate any dental appliance or prosthesis, a 50% down payment will
be accepted at the time of first impression. The remaining balance will be due upon delivery.
Our schedule is designed with you in mind. Appointment times are specifically reserved for you with your
provider. RESCHEDULING LESS THAN 48 HOURS IN ADVANCE OR MISSING AN APPOINTMENT
ENTIRELY WILL CARRY A FEE OF $50 TO $75 PER HOUR DEPENDING ON APPOINTMENT
TYPE.
Account balances over 30 days are subject to a finance charge.