Health History | Form 900

Personal Information

Medical History

Are you allergic to:

I have read the above questionnaire in its entirety and have answered all questions truthfully to the best of my knowledge. I hereby authorize the dentist(s), RDHAP(s) in charge to perform any and all treatment for my child or myself (if patient is minor). I also consent to such methods as x-rays, drugs, and agents as may be indicated in connection with the treatment. The consent will remain in effect until cancelled. I hereby authorize payment directly to RDHAP Edris Kareemzadeh or Luxoral Dental Hygiene Practice of Edris Kareemzadeh, of the group insurance benefits unless other written arrangements have been made prior to treatment. I understand that Luxoral Dental Hygiene Practice of Edris Kareemzadeh, RDHAP is a Fee for Service (FFS) practice and requires a $150 deposit for booking my appointment which is nonrefundable, nontransferable and the full remaining payment is due at the time services rendered. I also understand that there's a fee involved for Luxoral team to travel to my place for my dental hygiene services and the price is based county to county unless it is waived by Luxoral team member and I will be informed of such. I understand that I am financially responsible for all the charges. I hereby authorize release of any information relating to myself or dependent child, to be shared in order to obtain benefits and/or payment. I also understand that full payment is expected for services rendered at the time of visit. I also understand that I will be charged a fee of $100.00 should I not notify this practice of my cancellation without a 72-hour notice.