I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I also give my consent to the dentist to perform any treatment needed to improve my dental and oral health. I do realize that there is certain risk involve in performing dental procedures. Hereby I release the dentist and Emerald Forest Dental from any liability should any unwanted event happen as a result of the said procedure. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information may be collected, used and disclosed within the guidelines of the policy. I also give consent to give and get information regarding my insurance policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

If our office accepts assignment of benefits, we must collect the plan member’s (not the patient) consent:

I hereby assign my benefits, payable from claims submitted electronically, to Dr.Jannati and authorize payment directly to him
This authorization shall continue in effect until the undersigned revokes the same.