INNOVATIVE PERIODONTICS & DENTAL IMPLANTS
PATIENT INFORMATION
PERSON RESPONSIBLE FOR ACCOUNT
In case of emergency, please contact:
DENTAL INSURANCE INFORMATION
HIPAA AUTHORIZATION

By way of my signature, I provide this practice with my authorization and consent to use and disclose my protected health information (PHI) for the purposes of treatment, payment, and health care operations as described in the Privacy Notice.  (Health Insurance Portability & Accountability Act)

TREATMENT CONSENT

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my/my dependent’s periodontal needs.  Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and the doctor, including the use of human and animal graft derived materials, PerioLase Nd:YAG and diode setting laser assisted procedures, use of titanium based dental implants and components, amalgams and any other dental/periodontal material, and to employ assistance as required to provide proper care.  I consent to the use of anesthetics, sedatives, and other medication as necessary for my treatment.

I fully understand that using anesthetic agents embodies certain risks

FINANCIAL POLICY ACKNOWLEDGEMENT

I agree to be responsible for payment of all services rendered on my or my dependant’s behalf, regardless of possible insurance coverage. Payment is due at the time of service unless other arrangements have been made in advance.  A 1.58% finance charge (18% APR) may be charged on any balance over 60 days old

The cost estimates I am given are only estimates and unforeseen events may cause a change in the cost for my treatment

In the event financial arrangements are not adhered to, I understand the entire account balance will be considered delinquent and will be due and payable immediately.  I agree to be responsible for any reasonable collection costs or attorney fees incurred in collecting a delinquent account.

I hereby authorize payment of dental benefits otherwise payable to me to be paid directly to the dental provider.

 APPOINTMENT POLICY ACKNOWLEDGEMENT

The appointment time I schedule will be reserved for me and my prompt arrival will facilitate my treatment being completed in a timely manner. I am responsible for keeping my scheduled appointment regardless of any courtesy call or card I may or may not get. 

Prior notice of 14 DAYS is required to reschedule or cancel a periodontal surgery appointment; 48 HOURS notice is required to reschedule or cancel a non-surgical appointment.  The office utilizes a 24-hour answering system I may use for after-hours messages. 

A broken-appointment fee of up to 50% of the treatment amount scheduled for any appointment missed or cancelled without the above-required notification may be applied.  Exceptions in this policy can only be determined on an individual basis. 

By way of my signature, I understand and agree to the terms in the above appointment and financial policies and treatment consent.

HEALTH HISTORY

In order to provide your periodontal care in a safe and efficient manner, we ask you to update your Health History on a regular basis.  Please review each question carefully and answer as completely as possible.

Please indicate if you have a history of, or currently have, any of the following medical conditions:
I understand the above information is necessary to provide me with periodontal care in safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.
SIGNATURE OF DOCTORS: 
J. Jay Uemura, D.D.S.
Philip Vassilopoulos, D.D.S., D.M.D.