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Welcome to Stunning Smiles

On behalf of the entire team at Stunning Smiles of Las Vegas - Excellence in Dentistry, let me welcome you to our practice. We are grateful that you have chosen us to meet your dental needs, and trust that you will find your experience in our office to be pleasant, professional, and extraordinary.

You may discover that we are different from the average dental practice. When you visit our office you will find a unique and relaxing environment. Our team is friendly and attentive. All of our treatment is designed to be comfortable, to be long lasting, and to exceed all your expectations. We use the latest technology and techniques our profession has to offer. Our greatest strength lies in the unequaled advanced training in cosmetic and reconstructive dentistry we have received. It is for these simple reasons that we provide Excellence in Dentistry.

In order to better serve you, we are enclosing in this Welcome Packet several important documents that will assist us in making your transition to our office as smooth as possible. Please read each one carefully so that you can become familiar with our practice philosophy and policies. We are happy to answer questions you may have at any time.

Please find the enclosed questionnaire that should be filled out prior to your first appointment with Dr. Racanelli.

Be sure to visit our website at www.LVStunningSmiles.com. We look forward to serving all your dental needs for you and your family.

Yours truly for better dental health,
Richard A. Racanelli, DMD


Registration & Health History

REGISTRATION AND HEALTH HISTORY

Marital Status
Student Status
Employment Status
Please select Y = Yes or N = No if you have any of the following conditions:
Rheumatic Fever
Heart Disease
Heart Murmur (or MVP)
High Blood Pressure
Tuberculosis
Use Oral Contraceptives
Artificial Joint / Heart Valve
History of Endocarditis
Thyroid Disease
Anemia
Asthma
Diabetes
Are you nursing?
Might you be pregnant?
Hepatitis
If yes, what type of Hepatitis?
Radiation Therapy: Head I Neck
Seizure Disorder
Kidney Disease
Venereal Disease
Bleeding Problems
Cancer
Aids/HIV
Eating Disorders
History of HPV
Have you been hospitalized in the past five years?
Do you take aspirin on a daily basis?
Are you under a physician's care presently?
Have you ever been a drug or substance abuser?
Do you smoke?
I attest that I understand and answered all the above questions honestly and completely. I understand that the doctor is basing his treatment on this information. I authorize the release of information to insurance carriers and other health care professionals who are involved in my care. I assign my insurance benefits to Stunning Smiles of Las Vegas unless otherwise indicated.

*Your signature indicates you have received a copy of the HIPAA law and Dental Materials forms as well as releasing Richard A Racanelli, DMD to utilize any dental photographs for lecturing and educational purposes

Dental Health & Appearance

Have you ever had any serious problem associated with previous dental treatment or any dental emergencies?
What type of brush do you use?
Do you avoid brushing any part of your mouth because of pain?
Which foods cause you twinges of pain:
Do your gums feel tender or swollen?
Do you chew on only one side of your mouth?
Do you clench or grind your jaws while sleeping or during the day?
Do your jaws ever feel tired?

COSMETIC/ESTHETIC EVALUATION

Are you delighted with your smile?
Would you like to have whiter teeth?
Through state-of-the-art technology of cosmetic dentistry, we have the ability to help you achieve a world-class smile, often overnight using Dental Imaging and Digital Photography, we can simulate very closely how YOU would look after the improvements, PRIOR to any treatment! Imaging can be performed as part of your exam visit (at NO additional charge). Would you like to see what YOU would look like with a new and improved smile?
If yes, please select all that apply:

At Stunning Smiles of Las Vegas, though our focus is on appearance-related dentistry, our team also delivers routine general dental care as well. With flexible payment plans as well as phasing treatment over time, you and your family can achieve spectacular long-term results.
Thank you so much for the opportunity to be of service.

Warm Regards,
Richard A. Racanelli, DMD


Dental Expectations

We feel it is necessary to develop a rapport with our patients. Many new patients have had a past unpleasant dental experience. It is crucial to us to know and understand your concerns. We are committed to taking the time to get to know you, discuss your concerns, your fears, and your dental expectations.

Please place a check mark in the box next to the statement that concerns you or describes your problem.

Partnership Pact:

I ask that you honestly inform me of all my dental problems. I want you to make me aware of the best quality dentistry available today. Then we can discuss how I can make healthy choices that will work within my budget. I also want to know all the pain relief options available to me, how each dental procedure will work, and how much of my time will be required.

Consent For Use & Disclosure of Health Information

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment. payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office at (702) 736-0016 or by mailing us at 6410 Medical Center St., Ste. B, Las Vegas, NV 89148.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the address above. Please understand that revocation of this Consent will not affect any action we took before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Notice of Privacy Practices

You are entitled to receive our Notice of Privacy Practices upon request. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Included in the notice are:

    Your Rights

    When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

    Your Choices

    For certain health information, you can tell us your choices about what we share.

    Other Uses and Disclosures

    This section describes how we typically use or share your health information.

    Our Responsibilities

    We are required by law to maintain the privacy and security of your protected health information. This section describes all of our responsibilities in protecting your information.

To Request a Copy

We will provide a copy of our Notice of Privacy Practices to you upon request. Use the options below to indicate your preference:


I have been offered a copy of the Stunning Smiles of Las Vegas Notice of Privacy Practices.

Appointment Agreement

At Stunning Smiles of Las Vegas, we understand that your time is valuable. We are constantly striving to make your experience here more pleasant than any other place you have previously been. We make every effort to stay on time so that our patients will not have to wait unnecessarily.

Your appointment is a commitment of time between you and our office. We ask that you make every effort to keep that commitment. We do provide courtesy reminders and confirmation text messages at 30, 14, 7 & 3 days. Once you have confirmed your appointment with us, you will no longer receive the courtesy texts, EXCEPT for the same-day 2 hour reminder text about your upcoming appointment time.

In the event you do need to change your reserved time with our office, would you please give us 48 hrs notice so that we can offer your appointment time to another patient? We appreciate your cooperation.

Office & Financial Policy

Please read carefully and sign to acknowledge understanding and agreement.

Thank you for choosing us as your dental care provider! We are committed to providing you with the best dental care available. Below we have outlined several payment options to help you get the dental treatment you may need, want and deserve.

Available Payment Options

You can choose from - Cash, Check, Visa, Mastercard, American Express

We offer a 5% prepayment bookkeeping courtesy for to patients who pay for their treatment in full, at the time of scheduling. Financing is available, ask us for details.

Dental Insurance

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement on your behalf.

Your insurance is a contract between you and your insurance company. Stunning Smiles of Las Vegas is not part of that contract.

Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select services they will and will not cover.

If your insurance carrier does not pay the estimated benefit in full, you will be immediately responsible for any remaining balance. This balance may include any deductibles, co payments, denials and non covered services.

If we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees to our office and collection of your benefits directly from your insurance carrier.

Dental Benefits/Insurance

We will attempt to verify your benefit plan and give you as close of an estimate as we can for your treatment. Please understand that we don't know exactly how much your dental benefits will pay until the claim comes back. We do our best to give you an accurate estimate.

We will try to answer any questions we can about your dental benefit plan and, when possible we will assist in resolving any issues with claims. Please understand that we cannot speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your dental benefit company has not paid for your treatment, you will be responsible to pay your account.

Scheduling

We do collect your estimated patient portion or in order to reserve time in Dr. Racanelli's schedule, or for an appointment time with our hygienist longer than 1 hour (except for new patient appts.). This allows us to provide the highest level of care to our patients. Should you have a residual balance after your insurance claim is closed, we will reach out to you to let you know.

Collections on Balances due

A charge will be added to your account for any returned checks.

If you are experiencing financial difficulties in paying your balance, please reach out to use and we are happy to work with you to bring your account current.

Should your account be sent to collections, you are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorneys fees, interest, and late fees.

Responsible Party

As the responsible party, in the case where my spouse and/or children are also patients at Stunning Smiles of Las Vegas, signing this Office & Financial Policies will apply to them and their accounts as well.

Photos & Images

We take photos, of mouth, teeth, gums and smile as well as x-rays as part of our records. We sometimes also take intra-oral photos for documentation as well as for insurance claims.

I acknowledge and authorize Stunning Smiles of Las Vegas to take photographs, video and x-rays of my face, jaw, teeth and smile as a record of my care.

Please select from multiple choice question if you agree to have your full face before and afters shown, or just images of your teeth/smile before and afters shown.

Images/Photos

Occasionally we use patient case photos for social media and in our website gallery.

By signing this, you agree that your picture(s) can be shown publicly and you do not expect compensation, financial or otherwise for the use of these photographs.

Authorization For Release of Identifying Health Information

I authorize the professional office of my dentist, named above, to release health information identifying me (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following conditions:

  1. Detailed description of the information to be released:
  2. To whom may the information be released (names or classes of recipients):
  3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual):
  4. Expiration date or event relating to the individual or purpose for the release:

Other persons that my information may be shared with:

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose to not sign this authorization.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us your authorization is revoked. Send this note to the office contact listed above.

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

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