Consent of Treatment Form

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
	Last Name*	Middle Name	First Name*

Birthday:*

Home Address:*					City
	State		Zip		Apt#

Home Phone:*	()--
E-mail:*

How did you hear about us?
Have you visited our website?	Yes No
Whom may we Thank for referring you?


*	I hereby authorize Dr. Jamil Alkhoury or her designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by Dr. Jamil Alkhoury to make a thorough diagnosis of ’s dental needs.

*	Upon such diagnosis, I authorize Dr. Jamil Alkhoury to perform all recommended treatment mutually agreed upon me and to employ such assistance as required to provide proper care and I understand that treatment may change once decay has been removed.

*	I agree to the use of anesthetics and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

*	I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

*	I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.25% late charge may be added to my account. If required I also understand a check of my credit may be made.
*	By submitting the above form you agree and accept our Privacy Policy*


*Patient's Signature	Date

Patient testimonials

These video testimonials are from actual patients treated by Dr. Alkhoury after their consent to display their testimonials , results are not the same and may vary.

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Award Winning Dentistry With An Artistic Touch!

Testimonials

Rating : 5

- N.Z "The best dentist and office staff in the world!! I drive 4 hours from Northern Nevada to Brentwood for my dental needs. They are always so gentle and very interested in you. No pain ever and I had several crowns, root canals and deep cleanings done and not once did I experience pain and even afterward no soreness or pain. It may sound funny to say, But I love my dentist and his office staff!!"

Read our patient reviews

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Dentists Brentwood - Accredited Business