Demographic Information

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

FEES & PAYMENTS
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

I hereby authorize the release of all medical/dental information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care as well as to labs that need my information to make a diagnosis or fabricate an appliance necessary for my treatment.

Any payments made to the patient from the insurance company should be submitted to the office to cover the treatment rendered in the practice.

I assign all medical/dental and surgical benefits, including major medical benefits to which I am entitled to Dr. Usher and Dr. Ahghar. This assignment will remain in effect until revoked by me in writing. Photocopy of this assignment to be considered as valid as the original.

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

I hereby authorize and direct the dentists and supporting personnel of Carabelli Dental to perform the explained dental treatment(s) and/or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs, and/or other diagnostic aids. These treatments and/or procedures include, but are not limited to examinations, oral prophylaxis (cleanings), scale and root plane (SRP - deep cleaning), fluoride applications, sealants, restorations (amalgam or composite fillings and crowns), periodontal (gum) treatments, endodontic (root canal) procedures, implant placements, tooth removal.

I agree to use local anesthesia, the use of nitrous oxide/oxygen analgesia, IV sedation depending on the judgement of the doctors.

I understand that there are advantages, disadvantages and risks involved with dental treatment(s) and hereby acknowledge that the advantages, disadvantages and risks have been explained to me. I have had an opportunity to ask questions regarding the dental treatment(s) and the advantages, disadvantages and risks. I fully understand those advantages, disadvantages and risks and accept dental treatment(s).

The dental treatment(s) I am receiving has been explained to me. Alternate methods of treatment, if any, have also been explained to me, as have the advantages, disadvantages and risks of each. I am advised that, though good results are expected, the possibility and nature of complications cannot be accurately anticipated.

I recognize that during the course of treatment, unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorized and request the performance of any additional procedures that are deemed necessary or desirable.

I understand and have been informed that there are possible risks and complications associated with these dental treatment(s) and the administration of local anesthesia, nitrous oxide/oxygen analgesia, and/or IV sedation. The most common of these being swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa.

I have been given the opportunity to ask questions and give my consent for proposed treatment that will be provided at Carabelli Dental.

We value our patients’ time and strive to provide timely care to everyone. Missed appointments without proper notice impact our ability to serve other patients in need. The following policy applies to same-day no shows.

1. For a first same-day no show, the patient will be eligible to reschedule an appointment no sooner than one (1) month from the missed appointment date.
2. For a second same-day no show, the patient will be eligible to reschedule an appointment no sooner than six (6) months from the missed appointment date.
3. For a third same-day no show, the patient will not be eligible to reschedule. However, the patient may contact the office to request an appointment after one (1) year from the missed appointment date.

In any of these cases, patients experiencing emergency or pain-related dental issues may be considered for a same-day walk-in appointment based on provider availability. This is not a guaranteed appointment and is subject to scheduling capacity.

Patients have the option to seek out alternative dental professionals for their treatment at any time.

I _________ give AU Crown Enterprises, LLC DBA Carabelli Dental in Roswell, NM permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like. I agree that Carabelli Dental have complete ownership of such pictures, etc., including the entire copyright, and may use them for the purpose of but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet and social media posts. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release AU Crown Enterprises, LLC and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.

How Likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired?

Even if you have not done some of these things recently, try to determine how they would affected you. Use the following scale to choose the most appropriate number for each situation.

Interpretation of ESS Scores:

0-5: Low daytime sleepiness (normal).   6-10: Normal daytime sleepiness.   11-12: Mild excessive daytime sleepiness.   13-15: Moderate excessive daytime sleepiness.   16-24: Severe excessive daytime sleepiness.

Interpretation of STOP BANG:

0–2: Low risk of OSA   3–4: Intermediate risk of OSA   5–8: High risk of OSA