New Patient Forms
Shawn Sadri DMD
Cosmetic & General Dentistry
515 Madison Avenue
Suite 1710
New York, NY 10022
212-256-0687
office@DrShawnSadri.com
www.DrShawnSadri.com
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Last Name, First Name *
Cell Phone Number *
E-mail *
Address *
Gender *
Date of Birth *
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Social Security Number *
Do you have Dental Insurance? *
If so, who is your Dental Insurance Carrier?
Who is the primary subscriber on this Dental Insurance? If it is a family member, please write their full name, date of birth and social security number
What is your Dental Insurance Subscriber ID Number?
What is your Dental Insurance Group Number?
What is your Dental Insurance Group Name?
Dental Insurance Carrier Mailing Address
Dental Insurance Electronic Payer ID
Emergency Contact- Please write the full Name, relation to you and telephone number
Reason for your visit *
Date of last hygiene appointment
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Date of last X-Rays taken
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Do you have any allergies? If so please write them
Are you taking any medication? If so please write them
Medical History - Please write as much as you can. A more in-depth review will be asked at your initial appointment
By selecting Yes below you have read and agree to the following terms and conditions of being a patient with our practice: As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. 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 unless other arrangements are made. Patient with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. The office will help prepare the patient’s insurance forms or assist in making collections from insurance companies. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangement are satisfied. I understand that any fee estimate for this dental care can only be extended for a period of three months from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within one (1) day of billing if credit is extended. I further agree that the charges for services shall be billed unless objected to, by me, in writing within the time payment is due. 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 attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone / email / text me to discuss this statement or my treatment or finances. I grant my permission to the dental practice to upload and store confidential patient information (including account information, personal information, appointment information, clinical information and credit card information) to the secured website / database for the dental practice. I understand that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of a breach. Communication with Family: Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency. Appointment: We may use or disclose your health information to provide you with scheduling an appointment and/or appointment reminders (such as voicemail messages, text messages, MMS, postcard, email, fax, and/or letters). I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand that the dental practice will represent and warrant that they will, at all times during the terms of the Agreement and thereafter, comply with all laws directly or indirectly applicable that may nor or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all that information that is uploaded to the website on my behalf. I understand that the dental practice cannot and does not assume any responsibility for my use or misuse of patient information and other information. I agree to receive the dental practice emails / texts containing news, updates and promotions. You can withdraw your consent at any time in the notifications settings or by clicking on the unsubscribe link located at the bottom of the emails. Please be aware that if you cancel and/or reschedule your appointment within 48 hours or do not show up to your appointment, you will be charged a NO SHOW/CANCELLATION/RESCHEDULE Fee of $150.00. This fee must be paid in full prior to booking your next appointment. *
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