Dell A. Goodrick, DDS, FAGD

PATIENT INFORMATION DATE_____________________

NAME _________________________________________ MARRIED SINGLE CHILD MALE FEMALE

SOCIAL SECURITY / PATIENT ID __________________________________ BIRTHDATE __________________________

ADDRESS _____________________________________________________ CITY ________________________________ STATE _____ ZIP ______________

PHONES: HOME ____________________________________ WORK __________________________________ CELL _________________________________

EMAIL ______________________________________________ PREFERRED METHOD OF CONTACT ______________________________________________

PATIENT EMPLOYER ________________________________________ F/T STUDENT? ________________ SCHOOL __________________________________

EMPLOYER ADDRESS __________________________________________ CITY _________________________________ STATE _____ ZIP ______________

HOW DID YOU HEAR ABOUT US? _____________________________________________________________________________________________________

EMERGENCY CONTACT ___________________________________________ PHONE ____________________________ RELATION _____________________

RESPONSIBLE PARTY

PERSON RESPONSIBLE FOR THIS ACCOUNT _______________________________________________ RELATION ___________________________________

ADDRESS (If different from above) _______________________________________________________________________________________________________

PHONES: HOME ___________________________________ WORK _________________________________ CELL __________________________________

NAME AND ADDRESS OF EMPLOYER __________________________________________________________________________________________________

PRIMARY INSURANCE INFORMATION

NAME OF INSURED ______________________________________________________ RELATIONSHIP TO PATIENT___________________________________

BIRTHDATE ________________________________ SOCIAL SECURITY / INSURED ID __________________________________________

EMPLOYER ____________________________________________ ADDRESS ___________________________________________________________________

WORK PHONE _________________________________________

INSURANCE COMPANY _______________________________________________________ GROUP # _____________________________________

INSURANCE CO ADDRESS _____________________________________________________ CITY _________________________ STATE _____ ZIP _________

HOW MUCH IS YOUR DEDUCTIBLE? _____________ ANNUAL MAXIMUM __________________ REMAINING AMOUNT ___________________

SECONDARY INSURANCE INFORMATION

NAME OF INSURED ______________________________________________________ RELATIONSHIP TO PATIENT___________________________________

BIRTHDATE ________________________________ SOCIAL SECURITY / INSURED ID __________________________________________

EMPLOYER ____________________________________________ ADDRESS ___________________________________________________________________

WORK PHONE _________________________________________

INSURANCE COMPANY _______________________________________________________ GROUP # _____________________________________

INSURANCE CO ADDRESS _____________________________________________________ CITY _________________________ STATE _____ ZIP _________

HOW MUCH IS YOUR DEDUCTIBLE? _____________ ANNUAL MAXIMUM __________________ REMAINING AMOUNT ___________________

METHOD OF PAYMENT

PAYMENT IN FULL AT TIME OF VISIT

I WISH TO DISCUSS THE OPTIONS FOR THIRD PARTY FINANCING OF DENTAL CARE

PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED

DENTAL HISTORY

What is the nature of today’s visit? Exam Consultation Emergency __________________________________________________________________

Previous dentist ____________________________________________ Phone ___________________________________ City ____________________________

Date of last dental care ________________________________________________ Last X-rays ______________________________________________________

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU:

Bad breath

Grinding or clenching

Sensitivity to sweets

Bleeding gums

Loose or broken fillings

Sensitivity when biting

Clicking or popping of the jaw

Periodontal treatment

Sores or growths in the mouth

Trapping food between teeth

Sensitivity to cold

Sensitivity to hot

How often do you brush? _____________________________________ How often do you floss? _______________________________________

How do you feel about the appearance of your teeth? _______________________________________________________________________________________

Have you ever experienced an adverse reaction during or in conjunction with a dental procedure? If so, what? __________________________________________

Other information about your dental health or treatment? _____________________________________________________________________________________

MEDICAL HISTORY

Physician’s Name ___________________________________ City _____________________________________ Phone _________________________________

Date of last visit _____________________________________ Have you had any serious illness or operations? Yes No

If yes, please describe ________________________________________________________________________________________________________________

Are you currently under physician care? Yes No If yes, please describe ________________________________________________________________

Have you ever had a blood transfusion? Yes No If yes, please give approximate date _____________________________________________________

Have you ever taken Fen-Phen / Redux? Yes No Have you ever taken osteoporosis medications? Yes No

Women: Are you pregnant? Yes No Are you nursing? Yes No Are you using birth control medication? Yes No

Check if you have had any of the following:

AIDS / HIV positive

Anaphylaxis

Anemia

Arthritis, rheumatism

Artificial heart valve

Artificial joints

Asthma

Atopic (allergy prone)

Back problems

Blood disease

Cancer

Chemical dependency

Chemotherapy

Circulatory problems

Cortisone treatments

Cough, persistent

Cough up blood

Diabetes

Epilepsy

Fainting

Food allergies

Glaucoma

Headaches

Heart murmur

Heart problems

Describe _______________

Hemophelia/abnormal

bleeding

Herpes

Hepatitis

High blood pressure

Jaw pain

Kidney problem

Liver disease

Material allergies (latex,

wool, metal, chemicals)

Mitral valve prolapse

Nervous problems

Pacemaker / heart surgery

Psychiatric care

Rapid weight gain / loss

Radiation treatment

Respiratory disease

Rheumatic/scarlet fever

Shingles

Shortness of breath

Skin rash

Spina Bifida

Surgical implant

Swelling of feet or ankles

Thyroid disease/malfunction

Tobacco habit

Tonsillitis

Tuberculosis

Ulcer / Colitis

Venereal disease

Is patient currently taking any medications? If yes, please list all: Does patient have any drug allergies? If yes, please list all:

_____________________________________________________________ ____________________________________________________________

_____________________________________________________________ ____________________________________________________________

AUTHORIZATION

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my dentist if I, or my minor child, ever have a change in health.

I authorize the use of this signature as “signature on file” for all benefit submissions. I authorize the dentist to release any information necessary to secure payment of benefits. I understand that I am

financially responsible for all charges rendered, regardless of and benefit plan. I consent to the use and disclosure of my protected health information to carry out healthcare operations, treatment

and payment activities (HIPAA).

_________________________________________________________________________ _____________________________________________

Signature of Patient, Parent, Guardian or Personal Representative Date _________________________________________________________________________ _____________________________________________ Please print name of Patient, Parent, Guardian or Personal Representative Relation to Patient

I have received copies of the Dental Material Facts Sheet and HIPAA Privacy Practices __________________________________________________________

Oral Health Risk FactorsPatient's Name:

1. Do you smoke or have you EVER smoked? DYes DNo(If No, proceed to question 2)

The amount that you are presently smoking (Check ALL that apply)None (quit smoking completely) Less than 1 pack of cigarettes per day An occasional cigarAn occasional cigarette 1 -2 Packs of cigarettes per day Cigars on a daily / regular basisA few cigarettes per Day 2 or more packs of cigarettes per day Occasional pipe smoker

A pipe on a daily / regular BasisIf you have quit smoking, when did you quit?

Less than 6 months ago 6 months to a year ago 1 to 3 years ago Over 3 years ago

How many years have you or did you smoke?Less than 2 years 2-5 years 5-10 years 10-20 years Over 20 years

2. Do you / Have you EVER chew/chewed tobacco or use/used snuff or other similar substance? DYes DNo(If No, proceed to question 3)Are you STILL using smokeless tobacco or snuff? DYes DNo

If No, WHEN did you quit?Less than 6 months ago 6 months to a year ago 1 to 3 years Ago Over 3 years ago

How many years did you use or have you used smokeless tobacco?Less than 1 year 1-2 years 2-5 years Over 5 years

3. Approximate average amount of alcoholic beverages presently consumed per week:None Less than 1 per week 1-5 drinks 6-11 drinks 11-20 drinks Over 20 drinks

4. Do you have or have you ever had a substance abuse problem? DYes DNo

Describe5. Do you presently use any recreational drugs? DYes DNo

List6. Do you have or have you ever had an eating disorder? DYes DNo

If Yes, Please Specify:7. Do you have or have you ever had any head, neck or mouth piercing(s)? (Other than ears) DYes DNo

List8. Do you have or have you ever been informed that you have been infected with an

oncogenic strain (possible cancer-causing) of the Human Papilloma Virus (HPV)? DYes DNo

9. Please list your history or any family member's history of cancer:

10. Other concerns and considerations:

CONSENT—To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informedof the changes without fail. I also consent to allow this practice to contact any healthcare providers) and to have the patient's health information released to aid in care andtreatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice.I understand there are no guarantees or warranties in health or dental care

Signature Date(Parent or guardian, if patient is a minor)

Copyright © LED Dental, Inc. (osoa-os) Reviewed By:

Dell A. Goodrick, DDS, FAGD

FINANCIAL INFORMATION

We are committed to providing you with the best possible dental care.

Payment for services is due at the time services are rendered, unless prior payment arrangements have been made and

approved in writing. We gladly accept Visa, MasterCard, Discover, American Express, checks or cash. For larger

amounts, we also offer financing through Care Credit, Capital One Healthcare Finance, Springstone, and Chase Health

Advance.

A charge may be made for an appointment failed or cancelled without 48 business hours notice, at the rate of half the

scheduled treatment fee. Appointment time is reserved in advance and with short or no notice, we do not have the

opportunity to fill the time with another guest. We value your time and also ask that you please consider our efforts to

accommodate those guests needing or waiting to come in.

Returned checks are subject to additional collection fees and interest charges of 1.5% per month. If an account

becomes delinquent, the guarantor will be responsible for all legal fees incurred in collection of that account.

Your benefit plan is a contract between you, your employer and the insurance company and we are not a party to that

contract. We are your advocate to help you receive the maximum benefit provided by your benefit plan, and are happy to

assist you in understanding your specific plan. It is very difficult to estimate benefits and not all services are covered in all

contracts. All policies have limitations and restrictions in order to keep the premium lower to the employer or sponsor.

For example, some plans will reduce benefits to the “lowest standard of care,” such as giving allowance for a “silver”

filling rather than tooth-colored fillings. This does not dictate what treatment you are entitled to, should be done, or

change the treatment plan suggested for you; rather it is the limitation of the benefit paid for that type of procedure.

If you have any questions about the above information, please do not hesitate to ask. We are here to help you.

I understand that my insurance is an agreement between my insurance company and me. I also understand that I

am responsible for payment of my account, regardless of my insurance.

I give permission for Dr. Dell Goodrick and his team to take and necessary diagnostic films, photos or study

models to properly enable complete diagnosis and treatment.

I have read the above statements. I fully understand and agree to these terms and conditions.

_________________________________ __________________________

Signature of Responsible Party Date

Dell A. Goodrick, DDS, FAGD

With recent advancements in materials and techniques, many of our patients are inquiring about cosmetic dental procedures. In order to better serve you, please take a moment to let us know how you feel about the appearance of your smile. Name:_________________________________________________Date:______________

YES NO

Do you like the appearance of your teeth?

Are your teeth as straight as you would like them to be?

Are you happy with the length, width, and shape of your teeth?

Do you think you have a “gummy” smile?

Do you have any chipped teeth?

Do you have any missing teeth?

Do you have any spaces between your teeth?

Do you have any discoloration, stains, or spots on your teeth?

Would you like your teeth to be whiter?

Do you have any dental work that you do not like?

Do you have any silver fillings that you would like changed to white?

Do you know anyone that has any cosmetic dentistry that interests you?

From the above questions, which concerns you the most? _________________________________________________________________________ If you could change anything about the appearance of your teeth, what would it be? _________________________________________________________________________

Dell A. Goodrick, DDS, FAGD, FALD 23504 Lyons Avenue, Suite 104, Santa Clarita, CA 

www.drdell.com  (661) 254‐4000  drdell@drdell.com 

NOTICE OF PRIVACY PRACTICES

YourInformation.YourRights.OurResponsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required

to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or dental care item out-of-pocket in full, you can ask us not to share that information for the purpose

of payment or our operations with your dental or health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask,

who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other

disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter

to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation

In these cases we never share your information unless you give us written permission: • Marketing purposes

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you

We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. We may use or disclose your health information to provide you with appointment reminders, such as voicemail or text messages, emails, postcards or letters.

Bill for your services We can use and share your health information to bill and get payment from dental or health plans or other entities.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues

We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we

can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective Date of this Notice: September 23, 2013