Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
Patient Sign-in

PATIENT REGISTRATION FORM

Zakhor Dental

10921 Wilshire Blvd. Suite 904,
Los Angeles, CA 90024
(310) 208-0811

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )

I hereby authorize assignment of my insurance benefits directly to the provider for services rendered.

I fully understand I am solely responsible for any balance not paid by my insurance company.

(Please click below to draw/upload sign)
(Your IP Address : IP:18.207.249.15 )
Dental Information( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Do you have any of the following?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Aspirin
  •  Penicillin
  •  Codeine
  •  Acrylic
  •  Metal
  •  Latex
  •  Local Anesthetics
  •  Any other Allergies

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Women

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in the condition of my health or if my medications change, I will, without fail, inform the doctor at my next appointment.

(Please click below to draw/upload sign)
(Your IP Address : IP:18.207.249.15 )
( * mandatory to fill )
  •  As a courtesy, we attempt to confirm most appointments 48 hours in advance. However, if we are unable to reach you, keeping your appointment is your responsibility.
  •  We require an advanced 24 hour notice of cancellation or request to reschedule an appointment.
  •  Failure to reschedule or cancel your appointment in this time frame will result in a charge of $50 per 1/2 hour appointment(s) for general and $100 per 1/2 hour appointment(s) with specialists. Please note that all Monday appointments shall be canceled by 5 P.M. Friday or a broken appointment charge will be applied.
  •  As a condition of treatment by this office, financial arrangements must be made in advance. We depend upon timely reimbursement for the costs incurred in rendering 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.
  •  Patients 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. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any insurance payment to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
  •  A service charge of 11⁄2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements are satisfied.
  •  I understand that any fee estimate for dental care can only be extended for a period of six 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 five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of time or condition hereunder shall not constitute a waiver of any other term or condition and I further agree as the responsible party to pay all costs including but not limited to outside collection fees, bank fee, penalties and reasonable attorney fees.

I grant permission to you or your assignee, to telephone me to discuss this statement or my treatment.

(Please click below to draw/upload sign)
(Your IP Address : IP:18.207.249.15 )
HIPAA Consent( * mandatory to fill )

HIPPA Consent

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies and for health care operations like quality reviews.

I have been informed that I may review the practices Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.

I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing, excluding any for information already used or disclosed.

(Please click below to draw/upload sign)
(Your IP Address : IP:18.207.249.15 )
Copyright ©2019 SRS Web Solutions
Your browser doesn't support signing