Service Agreement and Informed Consent

This Service Agreement (“Agreement”) governs your use of the services of Azar Sona Saeidi DMD Inc., D.B.A. Soothing Dental (“Soothing Dental,” “Us” or “We”). By engaging our services, you agree that you have read, understand, and consent to this Agreement:

Service Acceptance

Patient has the legal right and ability to:
- Enter into this Agreement,
- Receive Dental Services for personal benefit or the benefit of their (his/her) legal minor children,
- Abide by the obligations, including the Terms and Conditions, set forth in the Agreement.
Patient acknowledges making an informed decision and agrees to a provider-patient relationship.
Patient authorizes necessary diagnostic, photographic, and therapeutic procedures for dental care.
Patient consents to health information disclosure for insurance and treatment purposes.
Patient agrees to update the dental office on any changes in medical or dental history.
Prescribed medication shall be for the patient’s or legal minor’s use only.
Patient is financially responsible for the services provided.
Patient understands risks such as infection or data privacy breaches.
Patient agrees to read all care instructions and medication info provided.
Patient consents to video/audio surveillance and understands usage rights.

Consent to Dental Treatment

Treatment To Be Done: Includes x-rays, cleanings, fillings, crowns, extractions, orthodontics, implants, etc.
Drugs and Medication: May cause allergic reactions including swelling, pain, or anaphylaxis.
Changes in Treatment Plan: Modifications may be necessary during procedures; additional costs apply.
Removal of Teeth: Alternatives will be explained. Risks include pain, dry socket, and nerve damage.
Crowns, Veneers, Bridges: Sensitivity may occur. Delays in final cementation may require remakes at additional cost.
Endodontic Treatment: Root canals may fail. Referrals and additional costs are the patient’s responsibility.
Periodontal Disease: Can cause bone loss and tooth loss. Surgery or extraction may be necessary.
Fillings: Post-treatment sensitivity may occur. Restoration longevity is not guaranteed.
Orthodontics: Results vary; compliance affects outcome. Retainers are necessary to maintain results.
Whitening Procedures: Cosmetic in nature. Not permanent; may cause sensitivity.
Patient has been provided a copy of the Dental Board of California’s Dental Materials Fact Sheet.
Dentistry is not an exact science and no results are guaranteed.
Patient authorizes the dental professionals to proceed with necessary treatment.
Specialists operate independently and guarantee their own work.

Terms and Conditions

A. Patient Responsibilities

Provide accurate information and update changes promptly.
Follow all dental recommendations and protocols.

B. Dental Services Provided

Services provided are at the discretion of the dental professional.
Charges are based on coverage or discount plan selected.
Billing will be handled by the dental practice.

C. Privacy and Security

Soothing Dental may use your personal health info in line with HIPAA and other regulations.

D. Electronic Health Record

Soothing Dental maintains electronic records of each patient (EHR).
These records include personal health information used during treatment.

E. Password and PIN

You are responsible for the security of your account credentials.

F. Financial Policy

Estimates are not guarantees of insurance payment.
50% deposit may be required for booking appointments.
Various payment methods accepted (credit card, HSA/FSA, etc.).
Late fees, default fees, legal action, and interest charges apply for non-payment.
Returned checks and card disputes incur additional fees.
Prepaid refunds are subject to a 4% processing fee.
Accounts not updated may result in stop-payment fees.

G. Discount Offers/Plans

Available for patients without insurance.
Discounts apply only to services provided by Soothing Dental.
Subject to changes and availability.

Note: This is a summarized and formatted version of the original Agreement. You should consult the original document or your provider for legal or detailed inquiries.

MONTHLY BASIS & TERM COMMITMENT

Payment for Discount Offers shall be made monthly using a valid credit card and will be processed automatically.

Any charges for Dental Services under Discount Offers must be paid at the time of service or through an arrangement mutually agreed upon between the Patient and Soothing Dental.

After the initial two-year commitment period (or any other term specified by the Discount Plan), the plan shall automatically continue on a month-to-month basis unless terminated by the Member.

Members may upgrade to a higher Discount Plan during the commitment period but may not downgrade.

Relocation or non-usage of benefits during the term is not valid grounds for early termination. In such cases, the Member remains liable for the full 2-year Service Fee or the UCR (Usual, Customary, and Reasonable) fee for services rendered.

H. APPOINTMENT CANCELLATION POLICY

A 48-business-hour notice is required for appointment cancellations or rescheduling.

A $75 fee per hour missed will be charged for cancellations without proper notice. The Member authorizes Soothing Dental to charge this amount to their selected payment method.

I. TERM, AUTO-RENEWAL, AND TERMINATION

This Agreement commences on the earlier of: (i) Member enrollment, (ii) appointment booking, or (iii) account creation on the Soothing Dental Site.

The Agreement automatically renews on the same terms unless either party provides at least 30 days’ notice before expiration.

Either party may terminate the Agreement at any time, with or without cause. Any balance must be paid in full upon termination.

After termination, Soothing Dental will retain Patient Records as required by law.

Early termination by the Member requires payment of the UCR fee for any services rendered and any outstanding fees.

Soothing Dental may terminate the Agreement with 30 days’ notice if the Patient fails to follow a recommended treatment plan.

Soothing Dental may terminate immediately if the Patient:

Harasses or discriminates against staff or others

Commits or threatens violence or brings a weapon to the premises

Appears under the influence

Steals or commits fraud

Lies or misrepresents information

Endangers staff or patient safety

Post-Termination:

If a balance remains after 15 days, Soothing Dental may charge the stored payment method.

All EHR access licenses will be revoked.

J. LIMITATION OF LIABILITY & INDEMNITY

To the maximum extent allowed by law:
(a) Soothing Dental is not liable for indirect, incidental, special, or consequential damages.
(b) Total liability is limited to the total amount paid by the Patient in the prior 12 months.

Member agrees to indemnify and hold Soothing Dental harmless for any liabilities arising from their actions or omissions.

K. DISPUTES

This Agreement is governed by California law and the California Arbitration Act.

Any disputes must be resolved via binding arbitration through JAMS in San Francisco, CA.

Each party covers its own arbitration costs; arbitrator fees are shared.

If arbitration is deemed invalid, disputes will be resolved in San Francisco courts.

Class action participation is waived.

Prevailing party is entitled to attorney fees and costs.

L. GENERAL PROVISIONS

This Agreement, along with the Consent to Treatment and Privacy Policy, constitutes the entire agreement.

If any provision is deemed unenforceable, the rest remains in effect.

Soothing Dental may request and store Patient’s Social Security number and government ID.

This Agreement binds the successors and assigns of both parties.

Headings are for convenience only.

This Agreement may be executed in counterparts.

Any modifications must be in writing and signed.

Revised agreements take effect upon signature. Refusal to sign a revised agreement may result in termination within 30 days.

NOTICE & CONTACT
Soothing Dental
450 Sutter St, #2500
San Francisco, CA 94108
Customer Service: (415) 989-3953

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