NEW PATIENT INFORMATION

I authorize my name to be used as "signature on file" on any insurance claim and to release any information relating to that claim, and to authorize payment directly to Nadia Navid, D.D.S.I authorize my name to be used as "signature on file" on any insurance claim and to release any information relating to that claim, and to authorize payment directly to Nadia Navid, D.D.S.

Payment: Payment is due at the time services are rendered. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment.

Scheduling of appointments: To maintain the utmost service and care, we do require at least 48-hour notice to reschedule an appointment. With less than 48-hours notice, a cancellation fee or deposit to reserve the appointment time again may be required.

Cell Phone:
regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time.
Patient Acknowledgements:
I hereby acknowledge that a copy of this practice'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 acknowledge that a copy of this practice's Dental Material Fact Sheet has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.