STEPHEN C. SNITZER, D.D.S.,

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STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed? DATE OF BIRTH SEX WEIGHT HEIGHT SOC. SEC. # ADDRESS: HOME: Street PHONE: City State Zip CELL: E-MAIL: BUSINESS: Company Name PHONE: Street OCCUPATION: City State Zip SPOUSE'S NAME (PARENTS - IF CHilD) SPOUSE'S OCCUPATION SPOUSE'S SOC. SEC. # SPOUSE'S DATE OF BIRTH SPOUSE'S EMPLOYER PHONE: Company Name Is this person an emergency contact? If not: Street City State Zip REFERRED BY: Name Phone PRIMARY DENTIST: DO YOU HAVE DENTAL INSURANCE?: PRIMARY DENTAL INSURANCE COMPANY: ** Relationship to insured: Insurance Company Name Street Address of Insurance Company Phone # Self Spouse Other City State Zip SECONDARY DENTAL INSURANCE COMPANY: Policy ID # Insurance Company Name Group # Phone # ** Relationship to insured: Street Address of Insurance Company Self Spouse Other City State Zip Policy ID # Group #

NAME: DATE:----------- Please complete the following questionnaire. This information is necessary for proper evaluation of your periodontal problem. Answers to the following questions are for our records and will be considered confidential. 1. Are you in good health?. 2. Are you now under the care of a physician?. 3. The name, address and phone number of my physician is 4. My last physical exam was on 5. Have you ever been hospitalized or had a serious illness or operation? EXPLAIN -------------------------------------------- 6. Do you have or have you ever had any of the following diseases? a. Rheumatic fever or rheumatic heart disease. b. Congenital heart disease. c. Cardiovascular disease (heart trouble. heart attack, mitral valve prolapse, other valvular disease, stroke, heart murmur). d. Artificial hip, knee or other joint replacement. e. High blood pressure,. f. Allergies. g. Hay fever,. h. Asthma. i. Fainting spells or seizures. j. Diabetes. k. Hepatitis, jaundice or liver disease. I. Arthritis or inflammatory rheumatism (painful swollen joints). m. Stomach or intestinal ulcers n. Kidney or bladder trouble o. Tuberculosis p. Epilepsy q. Bleeding or clotting problems. r. Low blood pressure s. Emotional problems...,.......... t. Anemia or other blood disorders u. Glaucoma............ v. Acquired immune deficiency syndrome (AIDS) or HIV positive w. Alcohol or drug abuse......,. 7. Do you have chest pain upon exertion?... 8. Do you smoke? If yes, how much?. This form continues on the reverse side of this page

9. Are you ever short of breath after mild exercise?. 10. Do you have to urinate more than six times a day?. 11. Are you thirsty most of the time?. 12. Have you had abnormal bleeding associated with previous surgery, extractions or accidents?. 13. Do you bruise easily?. 14. Have you ever required a blood transfusion?. 15. Have you ever had surgery or x-ray treatment for a tumor, growth or other condition? (Include cosmetic surgery) 16. Are you taking any of the following? Please list the name of any medication you are taking, the dosage and how often you take the medication. a. Antibiotics or sulfa drugs. b. Anticoagulants (blood thinners). c. Medicine for high blood pressure. d. Cortisone or steroids. e. Tranquilizers. f. Aspirin. g. Dilantin. h. Insulin or other drug for diabetes. i. Digitalis or drugs for heart trouble. j. Nitroglycerin. k. Birth control "pill". I. Vitamins and herbal supplements. m. Other ------------------------------------------ 17. Are you allergic to or have you ever reacted adversely to any of the following? a. Latex. b. Local anesthetics (Novocaine, etc.). c. Penicillin or other antibiotics (please list). d. Sulfa drugs. e. Barbiturates, sedatives or sleeping pills. f. Aspirin. g. Codeine or other pain medication (please list). h. Other 18. Have you had any of these drugs intravenously or orally for cancer or osteoporosis: Zometa, Aredia, Fosamax, Actonel or Boniva?. 19. Are you employed in any situation which exposes you to x-rays or other ionizing radiation?. 20. Do you have any other disease or condition that you think I should know about that was not listed? Explain Women 21. Are you pregnant? If so, due date 22. Are you nursing?. 23. Have you reached menopause? ~.

Dental Questionnaire Please answer the following questions about your dental health: 1. My mouth is: A. very comfortable. B. moderately comfortable. C. uncomfortable. 2. I: A. think the appearance of my mouth is excellent. B. am satisfied with the appearance of my mouth. C. am dissatisfied with the appearance of my mouth. 3. I: A. will do anything to keep my natural teeth. B. want to keep my teeth, but have a certain budget of time and money that I am willing to spend on them. C. don't care whether I keep my teeth or not. 4. I: 5. I: 6. I: A. have set goals for my oral health with my referring dentist. B. want to set goals concerning my dental health. C. never set goals concerning my dental health. A. have always done the best that was recommended for me. B. have not done what dentists have recommended for me. C. rarely go, and do not care much about having dental work completed. A. put dentistry for myself and family high on the priority list. B. put dentistry for myself and family low on the priority list. C. do not consider dentistry a priority. 7. I think my present state of dental health is: A. excellent. B. good. C. fair. D. poor. 8. I aspire to a mouth that is: A. in excellent health. B. in good health. C. pain free. 10. Have you had any serious trouble associated with previous dental treatment? 11. Is there anything you would change about your mouth or the appearance of your teeth? 12. These are the things that are important to me about my dental health: 13. What are some questions about dentistry and oral health that you have never had adequately answered? This form continues on the reverse side of this page

14. What is your number one concern about your mouth or jaws? 15. Do you have an immediate problem that you would like cared for today? If so, please explain 16. How long have you been with your present dentist? 17. How frequently have you had your teeth cleaned by a dentist or dental hygienist? 18. Has your present dentist done most of your dental treatment? 19. Has your dentist discussed your periodontal problem with you? 20. Have you noticed any of the following conditions occurring in your mouth? Bleeding gums 23. 24. 22. Do Have you you grind have hadfrequent or periodontal clenchheadaches? your treatment teeth? previously? If yes, to hot, cold or biting? Floss your teeth? If yes, do you wear a bite guard? 25. Does food wedge between your teeth? 26. Haveyouhadorthodontic~e~me~? 27. How do you feel about the possibility of wearing dentures? The above information is accurate to the best of my knowledge. I authorize the release of information from my dentist or physician to Dr. Stephen C. Snitzer. I authorize Dr. Stephen C. Snitzer to release information to my dentist or physician. Signature of Patient or Responsible Party Date

TO OUR PATIENTS WITH DENTAL INSURANCE Patient Signature Date Our office is happy to assist you with your insurance claims to help you achieve the maximum benefits under your plan. We will file for predetermination of benefits, if required, and file claims as your treatment progresses. To do so, we will require forms from your insurance company completely filled out and signed. We will accept payment directly from the insurance company if we receive your forms properly filled out in a timely manner. We will try to explain your coverage to you to the best of our ability. However, due to the variations among policies, your questions are best answered by your agent or employee benefits office where you work. No insurance plans cover 100% of treatment costs. Most plans have deductibles or co-payments that are the patient's responsibility. You will be expected to pay the estimated non-covered portion of treatment fees as your treatment progresses. If claims have not been paid within two (2) months from the time they were submitted, we will request that you contact your insurance company regarding the claim. All charges that have not been paid within three (3) months of the time that the claim was submitted are payable by the patient. The patient is ultimately responsible for all charges regardless of insurance coverage. I HAVE READ AND UNDERSTAND THE ABOVE. I AUTHORIZE THE RELEASE OF ANY INFORMATION REGARDING MY TREATMENT TO MY INSURANCE COMPANY OR THEIR REPRESENT ATIVES. I ALSO AUTHORIZE PAYMENT OF INSURANCE BENEFITS OTHERWISE PAYABLE TO ME TO BE PAID TO THE DENTIST. A PHOTOCOPY OF THIS SIGNATURE SHALL BE AS VALID AS THE ORIGINAL.

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