Welcome To

Flushing Family Dentistry !

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

1. About You

Date
Name
Dr
Mr
Mrs
Ms
I prefer to be called:
Sex:
M
F
Birthdate:
Age:
SS#:
Home Address:
City
State:
Zip:
Email:
Single
Married
Divorced
Widowed
Separated
Home#:
Cell#:
Work#:
Ext:
Employer:
Occupation:
Best time and number to reach you:
Who may we thank for inviting you to our office?
May we mention your name? :
Yes No
Previous Dentist
Last Visit:

2. Spouse/Parent Information

His/Her Name:
Birth Date:
SS#:
Work:
Ext:
Person responsible for account:
Relation:
SS#:
Billing Address:
Work#:
Home#:

6. Medical History

Your current physical health is:
Good
Fair
Poor
Are you taking any prescription/over-the-counter or herbal supplemental drugs?
Y
N
Please list each one:
Have you ever taken Phen-Fen (Redux or Pondimin)?
Y
N
For Women: Are you taking birth control pills?
Y
N
Are you pregnant?
Y
N
week#
Are you nursing?
Y
N
Have you ever had any of the following diseases or medical conditions?
Heart Problems/Conditions
Y
N
Blood Disorders (bleeding problems)
Y
N
Blood Transfusions
Y
N
High Blood Pressure
Y
N
High Cholesterol
Y
N
Stroke
Y
N
Cancer/Chemotherapy
Y
N
Radiation Therapy
Y
N
Diabetes
Y
N
Epilepsy/Seizures
Y
N
Fainting Spells
Y
N
Artificial Joints/Valves
Y
N
hepatitis
Y
N
HIV/AIDS
Y
N
Tuberculosis
Y
N
Psychiatric Problems
Y
N
Acid Reflux/GERD
Y
N
Liver problems
Y
N
Kidney Problems
Y
N
Osteoporosis
Y
N
Hearing/Vision Impaired
Y
N
Nervous Disorders
Y
N
Frequent Headaches
Y
N
Please explain/list any serious medical conditions that you have ever had:
Do you smoke/use tobacco in any form?
Y
N
Previously but quit
Do you drink alcohol?
Never
Occasionally
Weekly
Daily
Do you use street drugs?
Never
Occasionally
Weekly
Daily
What type?
Are you allergic to any of the following?
Y N
Aspirin
Y N
Erythromycin
Y N
Ibuprofen
Y N
Codeine
Y N
Metals
Y N
Penicillin
Y N
Tetracycline
Y N
Local Anesthesia
Y N
Latex
Please list any other drugs/materials you are allergic to:

3. Dental Insurance

PRIMARY
Dental Coverage:
Yes
No
Ins. Co. Name:
Ins. Co. Address:
Ins. Co. Phone:
Group#:
Insured’s Name:
Relation:
SS#:
Birthdate:
Employer:
SECONDARY
Dental Coverage:
Yes
No
Ins. Co. Name:
Ins. Co. Address:
Ins. Co. Phone:
Group#:
Insured’s Name:
Relation:
SS#:
Birthdate:
Employer:

5. Emergency Contact

In case of emergency, is there someone nearby we can contact?
Name:
Relation:
Home#:
Work#:
Cell#:

6. Medical History

Do you have a personal physician?
Yes
No
Physician:
Phone:
Last Visit:
Currently under care?
Yes
No

7. Dental History

Why have you come to the dentist today?
Do you require antibiotics for joint replacement or heart valve
issues before dental treatment?
Yes
No
Are you currently in pain?
Yes
No
Do you have a dry mouth?
Yes
No
Do you require antibiotics for joint replacement or heart valve
dental work?
Yes
No
Do you now or have you ever experienced pain/discomfort
in your jaw joint (TMJ/TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you like your smile?
Yes
No
Would you like whiter teeth?
Yes
No
Would you like fresher breath?
Yes
No
How many times a week do you floss?
How many times a day do you brush?
Type of bristles?
Soft
Medium
Hard
Do you grind/clinch your teeth?
Yes
No
Do you snore or have sleep apnea?
Yes
No

8. Informed consent

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence according to HIPAA regulations and it is my responsibility to inform this office of any changes in my medical status.

I also understand that if this office accepts my dental insurance, I am responsible for payment of my co-pay in full for services rendered the day of service. I also understand that I am responsible for payment of any deductibles and payments that my insurance does not cover.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Patient Electronic Signature:
Date:
OFFICE USE ONLY

Medical / Dental information above has been verbally reviewed with the patient named herein.

Signature:
Date:
comments:

Flushing Family Dentistry

INFORMATION FOR OUR PATIENTS WITH DENTAL INSURANCE

It is such a pleasure having you as a part of our dental family. Our mission is to provide you with the best quality dental care available today. To maintain our high quality of care we promise to base your treatment on your dental needs, not your insurance policy.

We are pleased that many of you have a dental insurance policy that will help you supplement the costs of your needed dental treatment. We will do everything we can to help maximize your benefits. Unfortunately, the insurance industry is changing so dramatically, that it has made it very difficult to keep up with the changes and how to maximize these benefits. Dental insurance is meant to be an aid to help functionally restore the mouth to sound dental health. It must be considered only as a subsidy for reconstructive dentistry. It has been the experience of many dentists; however, that patients have gotten the impression that their plan will pay up to 90%, even 100% of the dental fees. That is not always the case! Most plans cover from 30-40% of the average total fee. (Some may pay more- some less.) The percentage you receive is determined by how much your employer has paid for coverage. The less paid by the employer, the less you will receive in benefits.

The type of plan chosen by your employer determines insurance benefits. We are not involved with the insurance carrier in any way. Since dental services are rendered directly to the patient, the patient is responsible to us for payment. The insurance company, in turn, is responsible to the patient. Many patients choose to pay the dentist in full at the time of service and have the insurance company send payment directly to the patient. According to these patients the reimbursement check was received within 2-3 weeks as opposed to the normal 45-60 days when the insurance company has been directed to pay the dentist. We can only assume that because you and your employer are paying the premium for dental coverage they must live up to their contractual agreement. In other words, they do not want to lose the contract so they pay you in a very timely manner.

Since we have no say in the selection of your insurance company, we ask that you look upon your insurance as a vehicle that reimburses you for dental expenses. As a courtesy to you, our patient we will complete all forms pertaining to your claims and send them promptly to your insurance company. At this time we will wait for the estimated insurance payment for 60 days. If the claim has not been paid the balance will be transferred to your account. If you prefer to have your insurance company send payment directly to you we will provide you with a copy of the submitted claim and any additional information necessary.

Patient Electronic Signature
Date

HIPAA Notice of Privacy Practices

Niman Shukairy, DDS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you including demographic information, which may identify you and that, relates to your past, present, or future physical or mental health or condition related to health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physicians practice, and any other use required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for treatment may require that your relevant protected health information be disclosed to the health plan to obtain approval for the treatment.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of dental students, licensing, market and fundraising activities, and conducting or arranging for other business activities. For example, we may call you by name in the waiting room when your dentist or hygienist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceeding: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500.

Other Permitted and Required Disclosures

Will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization,

at any time, in writing, except to the extent that your dentist or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.

Under the Federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.

This means that you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your dentist is not required to agree to a restriction that you may request. If a dentist believes that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to obtain

a paper copy of this notice from us,

upon request,even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your dentist amend your protected health information.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, or your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to the Secretary of Health and Human Services if you believe that we have violated your privacy rights. You may file a complaint with us by notifying our privacy contact of your complaint; we will not retaliate against you for filing a complaint. This was published and becomes effective on/or before April 14, 2003

Patient Electronic Signature
Signature
Date

Flushing Family Dentistry

Treatment Consent Form


What you are being asked to sign is a confirmation that we have discussed the nature and the purpose of dental treatment, the known risks associated with dental treatment, and the feasible treatment alternatives, and that you have been given an opportunity to ask questions and all your questions have been answered in a satisfactory manner to your understanding. Please read this form carefully before signing it and ask about anything that you do not understand.

My signature on the bottom of this form certifies that:

  1. I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurance as to the outcome of prosthetic treatment or surgery can be made due to the uniqueness of every individual clinical situation. In most instances, the outcome of treatment is most satisfactory.
  2. I understand that unforeseen conditions or circumstances may arise during the course of treatment and that additional treatment not specified in my treatment plan may be necessary. I will be advised of any additional treatment and estimated costs should the need arise
  3. . I understand that the estimate given to me is for normal and usual treatment. I understand that if my treatment requires extra time, additional procedures, or additional laboratory work, there will be additional fees related to the additional time and treatment. Normal and usual treatment consists of 1 or 2 try-ins of the restoration and up to 5 post-insertion adjustments.
  4. I understand that Dr. Shukairy has carefully examined my mouth. Alternatives to the chosen treatment have been explained. I have been informed and I understand the purpose and the nature of the dental procedure. I understand the procedures that are necessary to accomplish completion of the dental treatment and fabrication of the prostheses.
  5. I have been informed of the possible risks and complications involved with surgery, drugs, and anesthesia that include but are not limited to the following: pain, swelling, infection, discoloration, inflammation of a vein, injury to teeth present, bone fractures, sinus penetration, delayed healing, and allergic reactions to drugs or medications prescribed. Numbness of the lip, tongue, chin, cheek, or teeth may also occur, for which the exact duration may not be determinable and may be irreversible.
  6. I have been informed of the possible risks and complications involved with dental treatment that include but are not limited to: root canal therapy, fracture of teeth or roots, fracture of porcelain or acrylic, loss of cementation, decay around restorations, and possible loss of teeth. I understand that these complications may necessitate further treatment.
  7. I understand that if nothing is done, any of the following could occur: loss of teeth, loss of bone, gum tissue inflammation, infection, decay, sensitivity, looseness of teeth followed by the need for extraction, fracture of teeth and/or roots, difficulties in chewing and/or speech. Also possible are temporomandibular joint (TMJ) problems, headaches, referred pains to the back of the neck and facial muscles, and tired muscles when chewing.
  8. Dr. Shukairy has explained that there is no method to accurately predict the outcome of dental treatment due to large variations in teeth, gums, bone, chewing forces, and oral hygiene. It has been explained to me that in some instances dental treatment may not be successful.
  9. I agree to follow the home care instructions provided to me. I agree to report to Dr. Shukairy for regular examinations as indicated and I understand that this office will monitor my progress unless I have been advised to return to my general dentist for dental care.
  10. To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, any blood or body diseases, gum or skin reactions, abnormal bleeding, or any other conditions related to my health.
  11. I consent to photography, study models, and X-rays of the procedure to be performed for use in teaching dentistry and other graphic purposes.
  12. I understand that with any dental treatment, my teeth, gums, or bone can be damaged by bacteria and I must do my utmost to remove the bacterial plaque off all the surfaces of all my teeth and/or implants every day. If I do not clean my teeth and/or implants properly, I may get decay and/or gum disease and my treatment may fail.

I have been fully informed of the nature of dental treatment along with possible risks and complications and hereby consent to treatment.

Date
Print Name
Electronic Signature Of Parent/Guardian
Date
Print Name
Signature Of Doctor
Date
Print Name
Signature Of Witness

Flushing Family Dentistry

Niman Shukairy, DDS

Thank you for choosing our office to meet your dental care needs. It is our optimal goal to provide you and your family with the highest quality of dental care, while maintaining a friendly and relaxing environment. In order to keep our standard of care to a level which best serves your needs, we ask you to please observe the following changes to our current office policies.

Cancellation Policy

There are many times that our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give our office advance notice of their need to cancel a scheduled appointment, this time can then in turn be allocated to these patients in urgent need of treatment. In this way, our office can best serve the needs of ALL of our patients.
Bearing this in mind, our office requires a minimum of 24 hours notice if an appointment must be canceled, 48 hours would be preferable. We do have an answering machine for your convenience so that a message may be left if an emergency comes up. Please be advised that if in the event that no notice is given and the patient does not show up for a scheduled appointment, then a $50.00 fee will be assessed. We do our best to remind our patients of your appointments, but it is ultimately your responsibility to remember your appointment. Please note that this fee is not covered by dental insurance and is the patient’s responsibility.

Dental Benefits/Insurance

Our office will collect your co-payment and bill your insurance using the information given to us. We are happy to do this as a courtesy to you and expect payment from your insurance company within 60 days. Normally, insurance companies will pay within 60 days. However, if we have not received payment from your insurance company after 60 days, the estimated insurance balance will become your responsibility.

Payment Options

To provide you with the best possible care, we expect you to pay your co-payment at the time of service. Please understand that payment of your bill at the time of service is part of your treatment. We work very hard to offer several options that help you afford necessary dental treatment.

  1. Receive a 5% bookkeeping courtesy for patient portion over $200.00 that is paid when the appointment is made.
  2. We accept cash, check, or money order.
  3. We accept Visa, MasterCard, or Discover Card for your convenience.
  4. We also offer extended financing through either Care Credit.
  5. A late charge of $5.00 per month will accrue on any account that is over 30 days old.
  6. Any account that goes over 60 days old will be referred for further collection activity and the account will be assessed a $36.00 administrative fee.
  7. Any returned check will be assessed a $30.00 return check fee to cover the bank fees that our office will accrue.
Patient Electronic Signature
Date