Women: Are you..

Are you allergic to any of the following? 

Do you have, or have you had, any of the following?

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 me (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I hereby give Sam Alawie, Mehrdad Razaghy DDS, and the BHDL Dental Center the absolute and irrevocable right and permission, with respect to the photographs that have been taken of me or in which I have been included with others:

(A) To copyright the same in their own name or any other name they may choose.

(B)  To use, re-use, publish and re-publish the same in whole or in part, individually or in conjunction with other photographs, in any medium and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion and advertising & trade.

(C)  To use my first name in conjunction therewith if they so choose.

I hereby release and discharge Sam Alawie, Mehrdad Razaghy DDS, and BHDL Dental Center from any and all claims and demands out of or in connection with the use of the photographs, including any and all claims for libel.

This authorization and release shall also ensure to the benefit of legal representatives, licensees, and assigns of Sam Alawie, Mehrdad Razaghy DDS, and BHDL Dental Center as well as, person(s) for whom the photographs were taken.

I am over the age of twenty-one. I have read the foregoing and fully understand the contents thereof.

Our notice of privacy practices is available to read below. Take a moment, read, and sign. 

I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my protected health information.

The Notice includes: - A statement that this practice is required by law to maintain the privacy of protected health information. - A statement that this practice is required to abide by the terms of the notice currently in effect. - Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment and health care operations. - A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization. - A description of uses and disclosures that are prohibited or materially limited by law. - A description of other uses and disclosure that will be made only with my written authorization and that I may revoke such authorization.

My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to: 1. The right to complaint to this practice and to the Secretary of HHS if I believe my privacyrights have been violated, and that no retaliatory actions will be used against me in the evenof such a complaint. 2. The right to request restriction on certain uses and disclosure of my protected health information, and that this practice is not required to agree to a requested restriction. 3. The right to receive confidential communications of protected health information. 4. The right to inspect and copy protected health information. 5. The right to amend protected health information. 6. The right to receive an accounting of disclosures of protected health information. 7. The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new guidelines effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy on request.

 

 

 

The dental materials facts sheet is must be ready by all patients receiving dental treatment. Please take a moment, read, and sign. 

I have carefully read and completed all sections of this form. The questions on this form have been accurately answered, and I am responsible to to communicate any changes with the clinic