New Patient Packet

Social Security Number is NOT collected here. Our front desk will ask for it at check-in to verify insurance benefits. (No action needed — this notice is for your awareness.)

I consent to receive reminders, occasional information, and promotions from Nhat Khanh Dentistry, Inc. (KinDentists).

I certify that I have provided accurate and complete medical history and have not knowingly omitted any information. I will promptly inform the office if I have any change in my health.

CANCELLATION POLICY. I understand that when I make an appointment with Nhat Khanh Dentistry, Inc. (KinDentists), the office considers it a mutual commitment and reserves the time and staff exclusively for me. The office policy requires at least 2 business days notice if I cannot keep the appointment. Otherwise, I may be charged a $35 late-cancellation fee for no-shows or missed appointments without a valid reason.

PRIVACY ACT / ELECTRONIC SUBMISSION. I understand that the required standards of personal information confidentiality are being met by Nhat Khanh Dentistry, Inc. (KinDentists) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the California Confidentiality of Medical Information Act (CMIA). I hereby authorize the release of information contained in claims to be submitted electronically or by mail to my insurance company. I have read and understood the above conditions and content.

FINANCIAL POLICY. For my convenience, Nhat Khanh Dentistry, Inc. (KinDentists) will prepare necessary reports to directly bill my insurance company. The estimated patient portion will be the balance due at the end of the treatment. The office accepts Cash, Debit, Visa, American Express, and MasterCard. I am responsible for all remaining balances that the dental insurance plan does not cover. I authorize and request my insurance company to pay benefits directly to Nhat Khanh Dentistry, Inc. or its affiliates.

RELEASE OF INFORMATION. I authorize Nhat Khanh Dentistry, Inc. (KinDentists) to release any information regarding my dental and medical history, diagnosis, or treatment to third-party payors and/or other health professionals as needed for billing and continuity of care.

DRUGS, MEDICATIONS, AND SEDATION. I understand that antibiotics, analgesics, anesthetics, and other medications may cause allergic reactions including redness, swelling, pain, itching, vomiting, and in rare cases anaphylactic shock. I will inform my dentist of any adverse reactions. I understand sedation and anesthesia carry risks including but not limited to nausea, prolonged numbness, and rarely more serious complications.

CHANGES IN TREATMENT PLAN. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy may become necessary following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.

FILLINGS. I understand that care must be exercised in chewing on fillings, especially during the first 24 hours, to avoid breakage. I understand that a more extensive filling or restoration than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common, but usually temporary, after-effect of a newly placed filling.

CROWNS, BRIDGES, AND CAPS. I understand the preparation of a tooth for a crown, bridge, or cap sometimes irritates the nerve, requiring root canal treatment. I understand temporary restorations may come off easily and that I must be careful to ensure they are kept on until the permanent restoration is delivered. I understand that the final opportunity to make changes is the time of the seating of the final restoration.

PERIODONTAL LOSS (TISSUE & BONE). I understand that I have a serious condition causing gum and bone inflammation or loss and that it can lead to the loss of my teeth. I understand that alternative treatment plans, including non-surgical cleaning, gum surgery, and/or extractions, may be required. Untreated periodontal disease may lead to additional dental and medical problems.

DENTURES (COMPLETE OR PARTIAL). I understand that wearing dentures can be difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placed the same day as extractions) may require considerable adjusting and several relines. I understand that a permanent reline will usually be required later — this is not included in the initial denture fee.

GUARANTEE OF RESULTS. I understand that no warranty or guarantee has been made regarding the outcome of any specific treatment. Dentistry is not an exact science. Treatment results depend on many factors including individual healing, oral hygiene, and home care.