ACKNOWLEDGEMENT OF PRIVACY PRACTICES

Mon , Wed 09:00-08:00

Tue , Thu 10:00-07:00

Fri - Sun 09:00-05:00

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718-441-2291

119-56 Metropolitan Ave.

Kew Gardens, NY 11415

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ACKNOWLEDGEMENT OF PRIVACY PRACTICES

First Name #

Last Name #

RELATIONSHIP TO PATIENT:
SELFPARENTGUARDIANOTHER

Please list any dependent children under the age of 18 also covered by this acknowledgement #

I give permission for the following communications to be used by Metropolitan Smiles Family Dentistry PC:
Cell phoneText Message reminders permittedHome phoneWorkEmail

I give permission for Metropolitan Smiles Family Dentistry PC to disclose their identity when calling; to anyone who may answer my phone:
yesno

I grant permission for Metropolitan Smiles Family Dentistry PC to leave a message on:
Home phoneWork PhoneCell PhoneWith any person who may answer when calling the home or cell phoneNone of above

I would like the following person(s) to have access to my personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above #

About Us

Artin Sakhaee DDS believes that maintaining good dental hygiene can help to improve the quality of life of his patient through both enhanced self esteem from cosmetic dental procedures and by resolving conditions which can affect a patient’s eating habits.

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Mon , Wed

Tue , Thu

Fri - Sun

9:00 am - 8:00 pm

10:00 am - 7:00 pm

9:00 am - 5:00 pm

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

Eating Habits

Gum disease effect on health

Smoking effect on gums