OFFICE POLICY AGREEMENT

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3 OFFICE POLICY AGREEMENT MINOR CONSENT FORM, If applicable: Cnsent t receive dental treatment: I hereby cnsent and authrize the dctrs and staff members t examine, clean and prvide dental treatment t my child. I further cnsent and authrize the taking f dental x- rays, as they may be cnsidered necessary t diagnse and/r treat my child. Minr Drp- Off Cnsent: In the event I drp ff my minr child t receive dental services, I hereby cnsent the dctrs and staff, t clean and prvide dental treatment t my child. I have listed a cntact persn t be reached in case f emergency belw: Name Phne Relatinship FINANCIAL POLICY I acknwledge that payment is due at the time f treatment, unless ther arrangements are made. I acknwledge that all financially respnsible parties are t be present fr all treatment planning and financial estimates. I agree that parents/guardians are respnsible fr all fees and services rendered fr treatment f a minr/child. I accept full financial respnsibility fr all charges nt cvered by insurance. In the event my accunt balance remains unpaid in excess f 90 days, I understand that my accunt will be turned ver t a cllectins agency. I accept full respnsibility fr all administrative csts and legal fees assciated with the cllectins prcess. I agree t reimburse the fees f any cllectin agency, which may be based n a percentage at a maximum f 54% f the debt, and all csts and expenses, including reasnable attrney s fees that the dental ffice incurs in such cllectin effrts. I understand that there is a brken appintment plicy and I may be charged $40, unless I ntify the ffice within 2 business days f my cancellatin. Fr yur cnvenience ur ffice takes persnal checks. Hwever, I understand a $50 fee will be applied t my accunt fr a bunced check (NSF) and frm that pint frward, persnal checks will n lnger be acceptable frm f payment. ASSIGNMENT AND RELEASE I, the undersigned, have insurance with and I authrize my insurance cmpany t assign benefits directly t my dental prvider, if any, therwise payable t me fr services rendered. I understand that I am financially respnsible fr all charges whether r nt paid by insurance within 30 days frm the date f service. I hereby authrize the dctr t release all infrmatin necessary t secure the payment f benefits. I authrize the use f this signature n all my insurance submissins whether manual r electrnic. WAIVER OF JURY TRIAL By signing belw, I heret irrevcably waive any and all right t trial by jury in any legal prceeding arising ut f r related t this agreement r any treatment services prvided by ffices affiliated with Narducci Dental Grup, P.A., its assciates, sharehlders, and emplyees. The scpe f this waiver is intended t be all- encmpassing f any and all disputes that may be filed in any curt and that relate t the subject matter f this agreement. By signing belw, I accept the abve terms set frth by the dental ffice and acknwledge full understanding f said terms. Signature Date

4 INFORMED CONSENT FORM FOR GENERAL DENTAL PROCEDURES Yu the patient have the right t accept r reject dental treatment recmmended by yur dentist. Prir t cnsenting t treatment, yu shuld carefully cnsider the anticipated benefits and cmmnly knwn risks f the recmmended prcedure, alternative treatments, r the ptin f n treatment. By cnsenting t treatment, yu are acknwledging yur willingness t accept knwn risks and cmplicatins, n matter hw slight the prbability f ccurrence. It is very imprtant that yu fllw yur dentist s advice and recmmendatins regarding medicatin, pre and pst treatment instructin, referrals t ther dentists r specialist, and return fr scheduled appintments. If yu fail t fllw the advice f yur dentist, yu may increase the chances f a pr utcme. The patient is an imprtant part f the treatment team. In additin t cmplying with the instructins given t yu by this ffice, it is imprtant t reprt any prblems r cmplicatins yu experience s they can be addressed by yur dentist. Certain heart cnditins may create a risk f serius r fatal cmplicatins. If yu (r a minr patient) have a heart cnditin, advise yur dentist immediately s yur physician can be cnsulted if necessary. If yu are a wman n ral birth cntrl medicatin yu must cnsider the fact that antibitics might make ral birth cntrl less effective. Please cnsult with yur physician befre relying n ral birth cntrl medicatin if yur dentist prescribes, r if yu are taking antibitics. As with all surgery, there are cmmnly knwn risks and ptential cmplicatins assciated with dental treatment. N ne can guarantee the success f the recmmended treatment, r that yu will nt experience a cmplicatin r less than ptimal result. Even thugh many f these cmplicatins are rare, they can and d ccur ccasinally. Sme f the mre cmmnly knwn risks and cmplicatins f treatment include, but are nt limited t the fllwing: 1. Pain, swelling, and discmfrt after treatment. 2. Infectin in need f medicatin, fllw- up prcedure r ther treatment. 3. Temprary, r n rare ccasin, permanent numbness, pain, tingling r altered sensatin f the lip, face, chin, gums, and tngue alng with pssible lss f taste. 4. Damage t adjacent teeth, restratins, r gums. 5. Pssible deteriratin f yur cnditin which may result in tth lss. 6. The need fr replacement f restratin, implants r ther appliances in the future. 7. An altered bite in need f adjustment. 8. Pssible injury t the jaw and related structures requiring fllw up care and treatment, r cnsultatin by a dental specialist. 9. Rt tip, bne fragment r a piece f dental instrument may be left in yur bdy, and may have t be t be remved at a later time if symptms develped. 10. Jaw fracture. 11. If upper teeth are treated, there is a chance f a sinus infectin r pening between the muth and sinus cavity resulting in infectin r the need fr future. 12. Allergic reactin t anesthetic r medicatin. 13. Need fr fllw up treatment, including surgery. This frm is intended t prvide yu with an verview f ptential risks and cmplicatins. Please discuss the ptential benefits, risks, and cmplicatins f recmmended treatment with yur dentist. Be certain all f yur cncerns have been addressed t yur satisfactin by yur dentist befre cmmencing treatment. Patient Signature Date Minr (Patient Signature) Date Print Patient Name Parent/Legal Guardian Date

5 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, hereby acknwledge that I have received and reviewed a cpy f Narducci Dental Grup, P.A., and affiliated dental practices HIPAA Ntice f Privacy Practices. I understand that Narducci Dental Grup, P.A., and affiliated dental practices HIPAA Ntice f Privacy Practices may change peridically and that I am entitled t receive a cpy f Narducci Dental Grup, P.A., and affiliated dental practices revised HIPAA Ntice f Privacy Practices upn request. I understand that, if I have questins abut Narducci Dental Grup, P.A., and affiliated dental practices HIPAA Ntice f Privacy Practices, I may cntact Narducci Dental Grup, P.A., at (904) I understand that it is my right t refuse t sign this Acknwledgement shuld I s chse, and that Narducci Dental Grup, P.A. and affiliated dental practices will nt refuse treatment t me if I refuse t sign this Acknwledgement. I further understand that I may cntact the Secretary f the U.S. Department f Health and Human Services shuld I have cncerns regarding Narducci Dental Grup, P.A. and affiliated dental practices privacy plicies and prcedures. Fr infrmatin n hw t cntact the U.S. Department f Health and Human Services, please ask Narducci Dental Grup, P.A., at (904) , nted abve, fr assistance. Patient Signature Date FOR OFFICE USE ONLY As privacy fficer, I attempted t btain the patient s (r representative s) signature n this Acknwledgment but did nt because: Refusal t sign Acknwledgement n, 20. Cmmunicatins barriers prhibited us frm btaining a signed Acknwledgement. An emergency situatin prhibited us frm btaining a signed Acknwledgement. Other (Describe): Date Received By Patient ID

6 DISCLOSURE BISPHOSPHONATE THERAPY AND CONSENT TO CONSERVATIVE SURGICAL AND NON- SURGICAL THERAPY. Bisphsphnates are a type f drug given t millins f Americans t treat steprsis r as part f cancer treatment, namely fr breast cancer, lung cancer, prstate cancer, multiple mylma, Paget s disease f the bne, alvelar necrsis f the bne r pst- menpausal steprsis. They are smetimes given rally and ther times are given thrugh peple s veins. Sme f the cmmn names include but are nt limited t: Actnel (Risedrnate) Bnefs (Cldrnate) Fsamax (Alendrnate) Fsamaz Plus D (Alendrnate) Aredia (Pamidrnate) Didrnel (Etidrnate) Bniva (Ibandrnate) Ostac Skelid (Tiludrnate) Zmeta (Zlendrnic Acid) Pamidrnate In rare instances, sme peple n these drugs have develped a cnditin called Ostenecrsis f the jaw, which results in severe damage t r lss f the jaw bne. Symptms include but are nt limited t pain, swelling r infectin f the gums r jaw, gums that are nt healing, lse teeth, numbness r a heavy feeling in the jaw, drainage and expsed bne. There is n prven treatment t fix this prblem. Accrdingly, patients n these drugs shuld knw the risks, benefits, and alternatives f invasive dental prcedures. If a patient is n Bisphsphnates, yur dentists, fllws special prcedures t prmte the safety f the patient. It is very imprtant that yu let the dentist knw whether yu are taking any medicatins, particularly a Bisphsphnates drug, r if yu have ever taken a Bisphsphnate drug. If yu are nt sure if the drugs yu are taking are Bisphsphnates, ask the dentist. Yu have a duty and respnsibility t tell the dentist all the drugs that yu take. I hereby disclse that: YES, I AM n a Bisphsphnate r have taken ne in the past. It is called: I have taken this medicatin fr: (Amunt f time) NO, I am NOT n any Bisphsphnates and have never taken r been given Bisphsphnates. PRINT NAME SIGNATURE DATE IF YOU CHECKED YES ABOVE, COMPLETE THE FOLLOWING: I UNDERSTAND THAT THE COMPLICATION STATED ABOVE CAN HAPPEN WITH SURGICAL AND NON- SURGICAL TREATMENT, AS WELL AS, SPONTANEOUSLY AND AGREE TO PROCEED WITH THE RECOMMENDED TREATMENT: PRINT NAME SIGNATURE DATE

7 PANORAMIC X-RAY As part f ur new patient evaluatin tday, a cmplete set f x- rays will be taken t prperly evaluate yur teeth. I understand these x- rays d nt capture the jawbnes, zygmatic bnes, stylid prcess, and maxillary sinuses. Additinally, I understand that the dentist cannt ensure cancers (malignant r benign), cysts, r ther abnrmal frmatins d r d nt exist in these areas, unless a panramic x- ray is taken. Insurance des nt cver the cst f this radigraph in cnjunctin with the x- rays that are necessary t prperly diagnse yur teeth. In rder t prvide the highest quality care and cmprehensive evaluatin pssible, we ffer this service, nrmally billed at $141.00, fr nly $ I understand that this fee will be charged t me tday shuld I wish t have a panramic film taken. WISHES t have a panramic x- ray taken tday Signature REFUSES t have a panramic x- ray taken tday Signature Date Chart ID: