FIRST NAME LAST NAME FIRST NAME LAST NAME Driver s Lic.# Employer Bus. Tel.( ) Ext. In case of emergency, please contact Tel.

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1 7375 W 52 nd Ave, Suite #330 Arvada, CO Ph: ENDO (3636) Fax: PATIENT INFORMATION... Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # Street Apt. City State Zip Home Tel.( ) Cell.( ) Have you ever been a patient of our practice? Yes No Has a family member ever been a patient of our practice? Yes No Dentist Medical Doctor FIRST NAME LAST NAME FIRST NAME LAST NAME Driver s Lic.# Employer Bus. Tel.( ) Ext. In case of emergency, please contact Tel. ( ) Relation WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT... Self (If self, skip this section) Spouse Father Mother Other Name S.S.# Birth Age Tel.( ) FIRST NAME Street Apt. City State Zip Driver s Lic.# Employer Bus. Tel.( ) DENTAL INFORMATION... Reason for today s visit LAST NAME Are you in pain? Yes No, For How Long? Please indicate any of the following problems by checking off the corresponding box: Discomfort, clicking, or popping in jaw Lost / broken filling(s) Stained teeth Difficulty closing jaw Red, swollen, or bleeding gums Teeth grinding / clenching Locking jaw Difficulty opening jaw Ringing in ears Bad breath Loose / shifting teeth Food caught between teeth Blisters / sores in or around the mouth Broken / chipped tooth Burning tongue / lips Swelling / lumps in mouth Prolonged bleeding from an injury / extraction Gum disease Toothache Recent infections or sore throat My teeth are sensitive to: Hot Cold Other Sweets Biting MEDICAL HISTORY... Are you in good health? Yes No Height Weight Are you under the care of a physician? Yes No Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No Pharmacy Name Tel. ( ) Have you had any illness, operation, or been hospitalized in the past five years? Yes No Have you, or a family member, had any unusual or serious reactions to general anesthesia? Yes No Do you have, or have you had, any of the following diseases, medical conditions, or procedures? (only check mark the boxes that apply) Rheumatic fever High blood pressure Low blood pressure Mitral valve prolapse Heart murmur Chest pain / Angina Heart attack(s) Irregular heart beat Cardiac pacemaker Heart surgery Damaged heart valves Pneumonia / Bronchitis / Chronic cough Chronic fatigue / Night sweat Trouble climbing 1-2 flights of stairs Anemia Asthma Mental health problems Problems with immune system (possibly from med. / surg.) Delay in healing Hay fever / Sinus problems Snoring Sleep apnea / CPAP Respiratory problems Tuberculosis Emphysema Do you smoke If so, # packs a day Do you use chewing tobacco A history of drug abuse A history of alcohol abuse Abnormal bleeding Bleeding tendency Blood transfusion Blood disorder Bruise easily Eye disease / Glaucoma Jaundice / Liver disease Hepatitis Gallbladder trouble Fainting spells Convulsions / Epilepsy Stroke Thyroid trouble Diabetes Low blood sugar Are you on dialysis Kidney trouble Sexually transmitted diseases Contagious diseases Infectious mononucleosis Swollen ankles Arthritis / Joint disease Prosthetic implant Joint replacement Osteoporosis / Osteopenia Osteonecrosis Stomach ulcers Tumor or growth Cancer / Radiation / Chemotherapy Are you on a diet Contact lenses

2 MEDICATION & ALLERGIES... Are you now taking: (only check mark boxes that apply) Nerve pills Pain killers (including aspirin) Antibiotics Blood thinners Diet pills Tranquilizers Insulin (Coumadin, Aspirin, Advil, Plavix) Blood pressure / Heart meds. Cholesterol Thyroid Are you taking, or have you Stimulants Antidepressants Steroids ever taken, any bone density Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products): meds. or bisphosphonates, MEDICATION DOSAGE FREQUENCY MEDICATION DOSAGE FREQUENCY such as Fosamax, Boniva, Actonel, IV Zometa, Reclast, geva, Prolia, or Aredia within the past 12 years. Are you allergic to, or had a reaction to: (only check mark the boxes that apply) Penicillin / Amoxicillin Sulfa drugs Local anesthetic (numbing med) Keflex Valium / other tranq. Aspirin / NSAIDS Codeine or other narcotics Latex Eggs / Yolk I have no known allergies Please list any other medication or antibiotic you are allergic to: MEDICATION / ANTIBIOTIC NAME MEDICATION / ANTIBIOTIC NAME 1-4 below for women only: (Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.) 1) Is there a possibility of pregnancy? Yes No 2) Pregnancy trimester: o 1st o 2nd o 3rd 3) Are you nursing? Yes No 4) Are you taking birth control pills: Yes No I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form. This signature on file is my authorization for the release of information necessary to process my claim, if I have insurance. I hereby authorize payment to this doctor named of the benefits otherwise payable to me. Signature of patient (Parent or Guardian if Minor) Reviewed by Copyright 2015 Protective Business and Health Systems, Inc. To re-order call

3 HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosure. In the event of your incapacity or emergency circumstance, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interests in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avoid a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable costbased fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $15.00 to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us by using the information listed at the end of this Notice for a full explanation of your fee structure.

4 hipaa continued Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Website or by electronic mail ( ), you are entitled to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy right, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternate means or at alternative location, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Clear Creek Endodontics 7375 W 52nd Ave Ste 330 Arvada, CO Signature of patient (Parent or Guardian if Minor) Financial Policy Our practice philosophy is based on quality service for our patients and we are committed to providing the highest quality of endodontic treatment. It is important to our professional relationship that you have a clear understanding of our Financial Policy, Fees, and Insurance. We are available at any time to discuss your proposed treatment and answer any questions. EVALUATION FEES Due to the nature of our specialty, the fee for evaluation and x-rays ($139.00) is collected in full if you do not have dental insurance. If it is determined that your dental insurance will not cover the consultation fee we will collect the fee up front. We must emphasize that as a dental care provider, our relationship is with you, not your insurance company. While filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. DENTAL COVERAGE Dental insurance is a highly complex area that creates confusion for dental patients. The complexities of dental insurance and the lack of sufficient information make it almost impossible for some patients to properly understand what their employer and the insurance companies have negotiated for your benefit package and stipulations. It is a contract between your employer and the insurance company. Clear Creek Endodontics is not involved in the agreement terms of your policy. However, our office will submit your claim to assist you in achieving the maximum reimbursement to which you are entitled. It is the patient s responsibility to contact their individual insurance carrier in order to discuss and understand the extent and limitations of your coverage. Our office participates in Assurant PPO, Cigna PPO, Connection Dental, Delta Premier, Dental Health Alliance (DHA), Dentemax and Dentegra insurance plans. Be advised that your referring dentist may participate in other dental plans and may not know what insurance companies we participate with. Your dentist has referred you to our office for your care. If you are a member of a PPO, HMO, Discount Dental Plan, Direct Reimbursement Plan or a dental plan that does not accept assignment of benefits to the doctor, payment is expected at the time services are rendered. It is customary to pay for services at the time treatment is rendered. We accept payment in the form of cash, check, and credit cards (Amex, Discover, Master Card, Visa, Care Credit, Citi Health and Debit Cards). If you are covered by dental insurance, we require a percentage of the total cost the day of the Root Canal Treatment. In turn, we will process your claim. Please note the amount not covered under your particular policy is your responsibility. A notification of balance due and a statement will be sent. Upon receiving and posting the insurance payment, if a credit exists a refund will be processed. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. NO DENTAL COVERAGE Patients without dental coverage are expected to pay the total fee on the day services are provided, unless special financial arrangements have been discussed and prearranged. COLLECTIONS If after three billing statements financial arrangements have not been arranged, your account will be sent to collections. Please note that an additional 20% of the balance will be added to your account if sent to collections. Patients are responsible for any court costs, collection fees, returned check fees and reasonable attorney fees. If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to address your concerns with our staff. We are here to assist you. Signature of patient: (Parent or Guardian if Minor)

5 PLEASE REVIEW THE FOLLOWING. YOU WILL BE REQUIRED TO SIGN PRIOR TO THE INITIATION OF TREATMENT; HOWEVER, IT DOES NOT COMMIT YOU TO TREATMENT. I hereby authorize Dr. John Newcomb and/or Dr. Ryan Stratton and whomever he designates as his assistant (s) to perform endodontic therapy as needed to treat my dental problem or condition. I further authorize the administration of medications and anesthetics, performance of diagnostic procedures, and such additional services that may be deemed reasonable and necessary, understanding that risks are involved. Possible alternative methods of treatment may include the following: endodontic surgical procedures, tooth removal, or no treatment, and the advantages or disadvantages of each will be discussed. I understand that I may also choose to decline treatment at this time and understand that the risks in not having treatment include, but are not limited to, pain, swelling, infection, increased bone loss, and eventual tooth loss. I also understand the following: In general, over 90% of routine cases are successful. Endodontics, as with any branch of medicine or dentistry, is not an exact science. Therefore, no guarantee of treatment success can be given or implied. If the case is not successful, the treatment may have to be redone, a surgical procedure may be required, or the tooth may have to be extracted. In each instance additional charges may apply. Cases started in other offices or retreatment cases are usually more difficult and may have a different outcome than expected under optimal conditions. It is usually necessary to alter the tooth structure or remove the restoration (e.g. crown or filling) of the tooth being treated. A proper post-treatment restoration (filling, onlay, crown, etc.) is a necessity. I also understand that only the Root Canal Treatment is to be performed at this office. It is my responsibility to contact my referring dentist soon after completion of the endodontic treatment to arrange for a post treatment restoration. Treatment will be performed in accordance with accepted methods of clinical practice. Included in the therapy will be the taking of a minimal number of x-rays as directed by the requirements of the case. A periodic recall examination is often recommended to evaluate the healing after treatment and no further charges are made for it. Compliance, however, is the responsibility of the patient. Possible complications of treatment include, but are not limited to, the following: A. procedural difficulties in the course of treatment; B. swelling, soreness, infection, trismus, paresthesia, or discoloration of the adjacent soft or hard tissues; C. fracture of the crown or root of the tooth or restoration; D. separation of the root canal instruments during treatment; E. perforation of the root with instruments; F. complications following local anesthetic injection (hematoma, paresthesia, allergy, increased heart rate, etc.); and G. additional unknown or unspecified problems, the explanation for and the responsibility of which cannot be given or assumed. I certify that I have read and understand the above authorization and informed consent and I am free to ask any questions pertinent to my treatment. Signature of patient: (Parent or Guardian if Minor)