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New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact Name: Phone: ( ) How would you like to receive reminders? (Please circle): Phone call, Email, Text Employer: May we contact you at work? YES, NO How did you hear about us? DENTAL INSURANCE Primary Dental Carrier Subscriber Name: SSN#: - - DOB: Insurance Company: Insurance Phone #: Employer: Group #: Relation to Patient: Secondary Dental Carrier Subscriber Name: SSN#: - - DOB: Insurance Company: Insurance Phone #: Employer: Group #: Relation to Patient: If patient is under 18: Relation to patient:

HEALTH HISTORY Name of Physician: Phone: Date of last physical: How do you assess your current health? Good Fair Poor Check the box to indicate if you have had any of the following condition: AIDS/HIV High Blood Pressure Jaw Popping Anemia Kidney Disease Limited Opening Arthritis, Rheumatism Liver Disease Congested Ears Artificial Heart Valves Mitral Valve Prolapse Posture Problems Artificial Joint Nervous Problems Clenching Asthma Pacemaker Grinding Bleeding Abornorally Psychiatric Care Facial Pain Blood Disease Radiation Treatment Neck Ache Cancer Rheumatic Fever Bell s Palsy Chemotherapy Scarlet Fever Do you Smoke? YES / NO Circulatory Problems Sinus Trouble Cortisone Treatments Stroke ALLERGIES Cough, persistent Swollen Feet/Ankles Aspirin Depression Swollen Neck Glands Codeine Diabetes Thyroid Problems Dental Anesthetics Epilepsy Tonsillitis Erythromycin Fainting or Dizziness Tuberculosis Latex Glaucoma Tumor in Head Metals Heart Lesions Ulcer Penicillin Heart Murmur Sleep Apnea Sulfa Heart Problems Headaches Tetracycline Hepatitis Type Jaw Pain Other: Are you currently taking prescription medications? If yes, please list below (name and purpose): WOMEN: Are you pregnant? YES / NO (if yes, expected delivery date: ) Are you breastfeeding? YES / NO Are you taking birth control pills? YES / NO

DENTAL HISTORY Previous Dentist: Phone: Date of last dental visit: Have you had a less than positive experience? YES / NO If Yes, please explain: How do you assess your current dental health? (Please circle): Good Fair Poor How often do you brush your teeth? How often do you floss? What other dental aids do you use? Electric toothbrush, Water-Pik, Soft-picks Please check any that apply: Bad breath/taste in your mouth Bleeding, swollen gums Broken tooth or fillings Clicking, popping in jaw Grinding or clenching Headache, ear aches, neck pain Jaw joint pain Loose, tipped, shifting teeth Mouth ulcers or cold sores Tooth pain or discomfort Sensitivity (hot, cold, sweet) On a scale of 1-10, with 10 being the highest rating: How important is your dental health? How would you rate your dental health? Importance of my overall health? Importance of preventive care to me? What is the most important thing to you about your visit today? What is the most important thing to you about your future smile and dental health? _ If you could change anything about the appearance of you smile, what would you want different? Have you been seen by an Orthodontist, had your bite adjusted, or treated for TMJ? If you could whiten your teeth for a cost anyone could afford, would you do it?

OFFICE POLICY NO SHOW AND CANCELLATION In order to continue providing excellent quality, yet affordable dental services, it is important for our patients to understand that appointments are reserved for you in advance; please make effort to keep your appointments. Please notify us within 48 hours if you need to cancel your appointment. In the event of a No Show or Cancellation without 48 hours notice, you will be required to pay a $50 Reschedule Fee before being placed back on the schedule, $25 of which can be used for future services. A $250 deposit will be required to reserve an appointment for your surgery date. This fee will be applied to dental work that is scheduled to be done. PATIENTS WITH DENTAL INSURANCE It is your responsibility to provide our office with your dental plan and to let us know of any changes at your appointment. We will continue to try and help you understand your policy but please be aware that there are thousands of different policies and we do not know all of the limitations for all of the plans out there. If for any reason your insurance company does not pay for a procedure, the balance is your responsibility to pay in full upon receipt of the statement. I AM RESPONSIBLE FOR MY BALANCE IF ANY OF THE FOLLOWING OCCUR: The treatment goes over my yearly maximum. Any treatment that is denied by my insurance company. I am not eligible for insurance. I prevent or delay by not complying with requests for insurance forms or signatures. I do not complete my treatment and it results in non-payment by the insurance company. Lab and equipment costs that incurred due to a missed appointment. I received my insurance check and do not send it to the office. By signing this, I have read and understand the above policy.

CONSENT FOR TREATMENT I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough, diagnosis of (patient name) s dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and the employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I give consent to the doctor s or designated staff to use and disclosure of any oral written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and healthcare operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protections of my personal health information is available. I agree to be responsible for payment of all services rendered on my behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made. HIPPA RELEASE OF INFORMATION I,, authorized the release of information including the diagnosis records; examination rendered to me and claims information. This information may be release to: Spouse Children Other Information is not to be released to anyone

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