I grant my permission to Dr. Antoine Varani to upload and store confidential patient information - including account information, appointment information and clinical information - to the secured web site for Dr. Antoine Varani. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand Dr. Antoine Varani and myself are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that Dr. Antoine Varani is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand Dr. Antoine Varani is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the Dr. Antoine Varani web site with my ID and password. I also agree to immediately notify Dr. Antoine Varani of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand Dr. Antoine Varani will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that Dr. Antoine Varani has the right to monitor, retrieve, store, upload and use my patient information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand Dr. Antoine Varani will use commercially reasonable efforts to maintain the confidentiality of all patient information that is up loaded to the web site on my behalf.
We, Dr. Antoine Varani, offer the convenience of an on-line payment service as part of our on-going program to better serve our patients. You may apply a specific amount toward your outstanding balance using a major credit card, debit card or check. You remain responsible for any charges and accrued interest on all late payments.
Each time you initiate a transaction, you authorize us or our agent to draw a check or draft or initiate an automated clearing house (ACH) or depository transfer check (DTC) debit in your name to the financial account you specify in the amount you request, payable to us or to our agent, in the amount of the transaction. For each transaction your bank may assess its customary per-check or item-handling charge, if any. You also agree to pay us a service charge for each dishonored check or draft to reimburse us for any costs of collection. Your bank may also assess its customary charge for such items.
While you may apply payment toward an outstanding balance today the payment may not be posted to your account for five business days. Please call our office if you require assistance.
I understand Dr. Antoine Varani CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
I have read and understand the information above regarding the secured uploading of patient information to the web site and the acceptance of payments for Dr. Antoine Varani.
We are delighted to welcome you to our practice and are pleased that you chose us to serve your dental needs
Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
Despite the most diligent care and precaution, unanticipated complications or unintended results, although rare, may occur. A treatment plan is based on the best evidence available during the examination, and there is no guarantee that this plan will not change. During treatment, it may be necessary to change or add procedures because of conditions that are not evident during examination, but were found during the course of treatment. Any change in a treatment plan may result in additional fees.
Services that may be provided include the following:
Care must be exercised in chewing on filled teeth, especially on large fillings and during the first 24 hours, to avoid breakage. Sensitivity can occur following a newly placed filling and will go away with time. I further understand that occasionally, upon injection of a local anesthetic, I may have prolonged, persistent anesthesia, numbness and/or irritation to the area of injection.
Crowns and Bridges:
I understand that it is not always possible to match the color of the natural teeth exactly with artificial teeth. I further understand that I will be wearing temporary restorations which could come off, and care must be taken to ensure that they are kept on until the permanent restorations are delivered. The final opportunity to make any changes to new crowns or bridges will be before cementation.
Removal of Teeth:
I understand that the purpose of the procedure/surgery is to treat, and correct my diseased oral tissues. Removal of teeth does not always remove the infection, if present, and further treatment may be necessary. If this condition persists without treatment or surgery, my present oral condition will worsen in time, causing additional treatment and costs.
Endodontic Treatment (Root Canal Therapy):
I realize there is no guarantee that root canal therapy will save my tooth, and that complications can occur from the treatment. I also understand that following root canal therapy, my tooth will be brittle and must be protected from fracture by placement of a crown.
Dentures (Complete and Partial):
The wearing of dentures can be difficult. Sore spots, altered speech and difficulty in eating are common problems. Due to bone loss, retention of full dentures can be a problem. Immediate dentures (placement of dentures after extration) may be painful, and may require considerable adjusting. I understand the importance of being present to all follow-up appointments.
I understand that no guarantee of assurance has been given that the proposed treatment will be curative and/or successful to my complete satisfaction. I agree to cooperate completely with the recommendations of the doctor while I am under his care. I understand that Antoine Varani, DDS INC, provides dental care without discrimination based on race, religion, national origin, sex, sexual orientation, physical or mental disability, age or marital status, and protects the privacy of each of its' patients.
I hereby instruct my Insurance Company to pay by check made out to:
Antoine Varani, D.D.S. Inc.
527 E. Olive Avenue, Turlock, CA 95380
for the fissional or medical expense benefits allowable and otherwise payable to me
under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebteness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original.
Article 1-Agrement Arbitration: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered , will be determined by submission to arbitration as provided by California Law, and not by lawsuit or resort to court process except as California Law provides for judicial review of arbitration proceedings. Both parties o this contract , by entering into it are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2-:All Claims Must Be Arbitrated: It is the intention and agreement of the parties that this arbitration agreement shall cover all claims or controversies relating to the matters described in Article 1 above, except claims within jurisdiction of the Small Claims Court, whether in (intentional negligent), contract or otherwise, including but not limited to suits relating to the matters described in Article1 and also involving claims for loss of consortium ,wrongful death ,discrimination, emotional distress or punitive damages. Arbitration pursuant to the terms of this Contract shall bind all parties whose claims as described in Article 1 may arise out of or in any way relate to treatment or services provided or not provided by Antoine Varani, D.D.S. Inc. Family and Cosmetic Dentistry ( Dr. Varani)or any employee or agent or providers of Dr. Varani, including any spouse or heirs of Patient and children, whether born or unborn, at the time of the occurrence giving rise to any claim. The undersigned understands and agrees that if the undersigned signs this contract in behalf of some other person for whom the undersigned has the responsibility, then in addition to the undersign, such person (s) will also be bound, along with anyone else who may have a claim arising out of the treatment of services rendered to that person.
The reference to Dr Varani includes the corporation, and its employees, agents and providers. Filing any action in any court by Dr. Varani to collect any fee from patient shall not waive the right to compel arbitration of any claim described in Article 1 . However, following the assertion of any claim against Dr. Varian ,any fee dispute, whether or not the subject of any existing court action, shall also be resolved by the same arbitration.
Article 3-Procedures and Applicable Law: Patient shall initiate arbitration by serving Demand of Arbitration on Dr. Varani and each defendant. The claim shall be mailed by U.S. mail, postage prepaid, Antoine Varani D.D.S. Inc, 527 E. Olive Ave, Site A ,Turlock ,CA 95382. A demand for arbitration must be communicated in writing to all parties, identify each defendant, describe the claim against each party, and the amount of damages sought, and the names, addresses and telephone numbers of the patient and his/her attorney. Patient and Dr. Varani shall each select an arbitrator, party arbitrator within 45 days of the Demand, and a third arbitrator (neutral arbitrator) shall be selected by the party of arbitrators within a reasonable time thereafter. In the event the claim is for less than $15000, the arbitration will be determined by a single, neutral arbitrator selected by the parties. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Civil Code 3333. I and 3333.2 of Civil Procedures 340.5, 667.7,1281-1295 and the Federal Arbitration Act (9 U.S.C. 1-9) as in effect from time to time.
Article 4-Retroactive Effect: Patient intends this contract to cover services rendered by Dr.Varani not only after the date is signed (including, but not limited to, emergency treatment), but also before it was signed as well.
Article 5-Severability: If any provision of this Arbitration Agreement is held invalid or unenforceable , the remaining provision shall remain in full force and shall not be affected by the invalidity of any other provision.
Dr. Varani's Agreement to arbitrate
In consideration of the foregoing agreements under this contract , Dr. Varani likewise agrees to be bound by the terms set forth in this Contract and to the rules specified in Article 3 above.