PATIENT INFORMATION. Patient name: Date of birth: Sex: Age: Home address: City: State: Zip: Billing address (if different): City: State: Zip:

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1 PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don t hesitate to ask. Patient name: Date of birth: Sex: Age: Home address: City: State: Zip: Billing address (if different): City: State: Zip: Home phone: Cell: Driver s license #: State: SS #: Employer/Occupation: Bus. Phone: Spouse s name & phone #: Primary dental insurance: Secondary dental insurance: Subscriber s name: Name of your medical doctor: Name of previous dentist: Emergency phone # (other than spouse): Group #: Group #: Date of birth: SS #: Date of last visit to medical doctor: Date of last visit to dentist: Referred to us by: DENTAL HEALTH HISTORY Are you apprehensive about dental treatment? Have you had problems with previous dental treatment? Do you gag easily? Do you wear dentures? Does food catch between your teeth? Do you have difficulty in chewing your food? Do you chew on only one side of your mouth? Do you avoid brushing any part of your mouth because of pain? Do your gums bleed easily? Do your gums bleed when you floss? Do your gums feel swollen or tender? Have you ever noticed slow-healing sores in or about your mouth? Are your teeth sensitive? Do you feel twinges of pain when your teeth come in contact with: Hot foods or liquids? Cold foods or liquids? Sours? Sweets? Do you take fluoride supplements? Are you dissatisfied with the appearance of your teeth? Do you prefer to save your teeth? Do you want complete dental care? How often do you brush? How often do you floss? Does your jaw make noise so that it bothers you or others? Do you clench or grind your jaws frequently? Do your jaws ever feel tired? Does your jaw get stuck so that you can t open freely? Does it hurt when you chew or open wide to take a bite? Do you have earaches or pain in front of the ears? Do you have any jaw symptoms or headaches upon awaking in the morning? Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? Do you find jaw pain or discomfort extremely frustrating or depressing? Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? Do you have a temporomandibular (jaw) disorder (TMD)? Do you have pain in the face, cheeks, jaws, joints, throat, or temples? Are you unable to open your mouth as far as you want? Are you aware of an uncomfortable bite? Have you had a blow to the jaw (trauma)? Are you a habitual gum chewer or pipe smoker?

2 MEDICAL HEALTH HISTORY: Do you have, or have you had, any of the following? Heart Problems Chest pain Shortness of breath Blood pressure problem Heart murmur Heart valve problem Taking heart medication Rheumatic fever Pacemaker Artificial heart valve Blood Problems Easy bruising Frequent nosebleeds Abnormal bleeding Blood disease (anemia) Ever require a blood transfusion? Allergy Problems Hay fever Sinus problems Skin rashes Taking allergy medication Asthma Intestinal Problems Ulcers Weight gain or loss Special diet Constipation/Diarrhea Kidney or bladder problems Bone or Joint Problems Arthritis Back or neck pain Joint replacement (e.g., total hip, pins, or implants) Fainting Spells, Seizures, or Epilepsy Stroke(s) Frequent or severe headaches Thyroid problems Persistent cough or swollen glands Premedications required by physician Cancer/Tumor Are you allergic, or have you reacted adversely, to any of the following? Local anesthetics ( vocaine ) Penicillin or other antibiotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin, Acetaminophen, or Ibuprofen Codeine, Demerol, or other narcotics Reaction to metals Latex or rubber dam Other tes: Date: Diabetes Urinate more than 6 times a day Thirsty or mouth is dry much of the time Family history of diabetes Tuberculosis or other respiratory disease Do you drink alcohol? If so, how much? Do you smoke? If so, how much? Hepatitis, jaundice, or liver trouble Herpes or other STD HIV-positive/AIDS Glaucoma Do you wear contact lenses? History of head injury? Epilepsy or other neurological disease? History of alcohol or drug abuse? Do you have any disease, condition, or problem not listed previously that you feel we should know about? If so, please describe: During the past 12 months, have you taken any of the following? Antibiotics or sulfa drugs Anticoagulants (e.g., Coumadin) High blood pressure medicine Tranquilizers Insulin, Orinase, or similar drug Aspirin Digitalis or drugs for heart trouble Nitroglycerin Cortisone (steroids) Natural remedies nprescription drug/supplements Other Women Are you taking contraceptives or other hormones? Are you pregnant? If so, expected delivery date: Are you nursing? Have you reached menopause? If so, do you have any symptoms? Patient Name: Patient/Parent Signature: Dentist Initial: N-RM/701R3 1/05

3 Form-CSI_PATT SLEEP EVALUATION / CLINICALS PATIENT NAME: DOB: GENDER: M F HEIGHT: WEIGHT: DIABETES STROKE DEPRESSION GERD Please check any of the following you may have: INSOMNIA ERECTILE DYSFUNCTION OBESE HYPERTENSION FREQUENT URNIATION AT NIGHT MORNING HEADACHES SNORING WAKING, CHOKING, GASPING FOR AIR Please check YES or NO to the following questions: HEART DISEASE COPD 1. Do you snore or have been told that you snore? 2. Do you often feel tired, fatigued, or sleepy during daytime? 3. Has anyone observed you stop breathing or gasp for air during your sleep? 4. Do you have or are you being treated for high blood pressure? If you answered to 2 or more of the above, please continue: Epworth Sleepiness Scale 1. Do you get sleepy, or doze off, while sitting and reading? 2. Do you get sleepy, or doze off while watching TV? 3. While Sitting or inactive in a public place? 4. As a passenger in a car for an hour without a break? 5. Lying down to rest in the afternoon? 6. Sitting and talking to someone? 7. Sitting quietly after Lunch without alcohol? 8. IN a car, while stopped for a few minutes at a traffic light? Never Doze off Slight Chance of dozing Moderate Chance of dozing High Chance of Dozing Total Score Have you ever been diagnosed with Sleep Apnea? Are you currently using CPAP? (or any other apnea/snoring device) Are you currently taking any sleeping aids (prescribed or OTC)? Are you aware of clenching or grinding your teeth? PROVIDER SIGNATURE: Date: Form_CSI007J

4 Silvia Cardona DDS Dina Chan DDS Jennifer Nguyen DMD Office Financial Policy Thank you for choosing us as your dental care provider. Our office is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy. REGARDING PAYMENT We accept the following forms of payment: cash, check, debit card, Visa, Discover and American Express. We also accept applications for no interest payment plans from CareCredit (3 or 6 months) or 12 months interest free for treatment over $3,000. Payment is due at the time services are rendered, unless prior arrangements have been made with the billing specialist. We offer a 5% courtesy accounting adjustment to patients who pay their whole treatment in full for treatment exceeding $500. REGARDING INSURANCE Our office will do everything to help you receive your maximum allowance benefits to the best of our ability. However, your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some and perhaps all of the services provided may be non covered services and not considered reasonable and customary under the terms of your insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary to our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. All insurance estimated co pays and deductibles must be paid at time of service. We will be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations 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. REGARDING CANCELLATIONS Our hygienists are paid even when patients cancel. A fee of $50 is charged to patients who cancel twice in one calendar year or fail to give 48 hour notice. Cancellation fees for appointments made with Doctor are based on length of time scheduled at $100/hr. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. I have read and understood the financial policy. Signature of patient or Responsible party: Date:

5 EL SEGUNDO BEAUTIFUL SMILES 390 N SEPULVEDA BLVD STE 1150 EL SEGUNDO CA I,, consent to be a patient at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following: 1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. 2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. 3. guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results. 4. I will pay in full any cost of treatment or insurance copayments according to the office s financial policy. I understand that even if an insurance preestimate is given or a procedure has been preapproved, I am responsible for any costs that my insurance does not cover. 5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff. 6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about. Patient or Guardian Name Date Patient or Guardian Signature