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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

If yes, please explain: __________________________________________________ If yes, please explain: __________________________________________________ If yes, please explain: __________________________________________________ If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

Are you under a physician's care now? Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury? Do you use tobacco?

Do you take, or have you taken, Phen-Fen or Redux? Are you on a special diet?

Have you been told to pre-medicate for dental procedures? Do you use controlled substances or recreational drugs?

Are you taking blood thinners? Have you ever taken Fosamax, Boniva, Actonel, Zometa

or any medication containing bisphosphonates? Have you ever been daignosed with Infective Endocarditis?

Yes Yes

Are you allergic to any of the following?

Yes No Taking oral contraceptives? Yes No

Do you have, or have you had, any of the following?

AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions

No No No No No No No No No No No No No No No No No No No

Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Yes

Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No No No No No

Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o No

Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/ Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice

N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o N o

Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s Yes

If yes, please explain: ___________________________________________________ If yes, please explain: ___________________________________________________

Have you ever had any serious illness not listed above? Yes No If yes, please explain: ____________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________

Comments:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY

Women: Are you Pregnant/Trying to get pregnant? No Nursing? Yes

Local AnestheticsLatex Other________________

SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________

Emergency Contact Name:_____________________ Relationship__________________ Phone:__________________ Alternate Phone:_________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

No No

Please list current medications, along with doses and frequency: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PATIENT NAME ________________________________________________ Today’s Date:______________Birth Date ________________

DENTAL HISTORY

PATIENT NAME ________________________________________________ Birth Date ________________ Today’s Date:______________

On a scale of 1-10, with 10 being the highest rating:

Smile MakeoverMissing TeethCrowdingSpacesChipped TeethBiteColor Whiter Teeth

What would you like to change about your smile?

Please share the following dates:

Your last cleaning _______/_______ Your last oral cancer screening _______/_______ Your last complete X-rays _______/_______

Please mark (x) any of the following conditions that apply to you

Periodontal (Gum) Health

Bleeding, Swollen, Irritated gums Bad breath Loose tipped, shifting teeth Previous perio/gum disease

Discolored teeth Worn teeth Misshaped teeth Crooked teeth Spaces Overbite Flat teeth

Appearance

Function

Grinding/Clenching Headaches Jaw Joint (TMJ) pain Jaw Joint (TMJ) clicking/popping Bad Bite Speech Impediment Mouth Breathing Sore Muscles (neck, shoulders) Difficulty Opening or Closing Difficulty Chewing on either side

Sleep Pattern or Conditions

Sleep Apnea Snoring Daytime Drowsiness Bed wetting (for children)

HabitsThumb sucking Nail-biting Cheek/Lip biting Chewing on ice Chewing foreign objects

Sensitivity (hot, cold, sweet) Pressure Broken teeth/fillings Worn teeth Dry Mouth

Pain/Discomfort

Please list any other oral conditions or concerns you may have: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

What is the most important thing to you about your future smile and dental health?________________________________ __________________________________________________________________________________________________ What is the most important thing to you about your dental visit today? __________________________________________ __________________________________________________________________________________________________ Why did you leave your previous dentist? _________________________________________________________________ __________________________________________________________________________________________________

How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10Where would you rate your current dental health? 1 2 3 4 6 7 8 9 10Where do you want your dental health to be? 1 2 3 4 5 8 9 10

What is your level of dental anxiety? 1 2 3 4 5 6 87

765

9 10

Thank you for choosing our office as your dental healthcare provider. We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment. Payment is due at the time service is provided. Our office accepts cash, personal checks, credit cards and outside patient financing. PAYMENT AT TIME OF SERVICE As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Ferdos Family Dental requires payment in full for your portion or anything not ESTIMATED to be covered by your insurance company (if you carry dental insurance) at the time of service. We accept Visa, Discover, MasterCard, as well as cash and checks. For more extensive treatment plans, patients have the opportunity to earn a 5% off courtesy on any treatment plan over $2,500. For patients to receive this discount, their entire treatment plan must be paid for in full, prior to treatment with check or cash. We will still file a claim for insurance reimbursement as a courtesy. EXTENDED PAYMENT OPTIONS For patients with larger treatment needs, we also provide affordable financing options through CareCredit Dental Financing Plans. CareCredit is designed specifically for healthcare-related expenses, and offers financing plans that feature no interest and low monthly payments. There are no annual fees, up-front costs, or pre-payment penalties. Once you are approved, you can use CareCredit repeatedly to help manage health and wellness costs that are not covered by insurance. To learn more about CareCredit, visit www.CareCredit.com or ask us for more information. DENTAL INSURANCE Patients who carry dental insurance should understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. At Ferdos Family Dental, we are happy to help prepare the patients insurance forms or assist in making collections from insurance companies as a courtesy and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. While we will keep an updated computerized history of payment for services by a given insurance company, these do change, often making it impossible to give a guaranteed quote at the time of service. We will ESTIMATE your portion of the payment, based on the newest information we have, and this is the amount that you will be responsible for at the time of service. Patients who have a DIRECT REIMBURSEMENT plan (the insurance company pays directly to the patient) are required to pay for services in full at the time of treatment. We will still file your claim to your insurance company on your behalf. It is important to understand that if your insurance company has not provided payment within 30 days, unpaid balances then become the responsibility of the patient. If your insurance pays you directly, you are responsible for payment in full, at the time of service.

There is a $50 fee for any checks returned by the bank.

OFFICE POLICIES

SERVICE CHARGE service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

Patient Name: _________________________________________ Signature of Guarantor: __________________________________________

Date: _________________________ Relationship to Patient:__________________________________________

MISSED APPOINTMENTS When we schedule an appointment for you, we are reserving a specific amount of time for your treatment. We strongly encourage our patients to keep their appointments. We understand that emergencies happen, and that you may face a situation that prevents you from attending your appointment. We ask that patients give a 48-hour notice when this occurs, so that we can use the appointment time to treat another patient. Without proper notice we are unable to offer the time to other patients who may be needing immediate care and are forced to charge a cancelled appointment fee at our discretion to your account. If you miss more than one appointment or cancel with less than 24-hour notice, we will ask you to pay a $50 fee and/or prepay for your next appointment.

EMERGENCIES If you are experiencing a dental emergency, we will do our best to get you into the office. Because we will be working you into our schedule, we ask that you pay for your emergency visit in full, even if you have dental insurance, since we may not be able to verify your coverage at that time. If you are a patient of record in our office, we will file your insurance claim as usual and only ask for your portion of payment.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you (the patient). The Notice contains a Patient Rights section describing your rights under the law (this may be requested at the front desk). You have the right to review our full Notice before signing Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict protected health information about you that is used or disclosed for treatment, payment or healthcare operations. By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: * Protected health information may be disclosed or used for treatment, payment or health care operations * The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. * The practice reserves the right to change the Notice of Privacy Policy. * The patient has the right to restrict the use of their information. * The patient may revoke this Consent in writing at any time and all future disclosures will then cease. * The Practice may condition treatment upon execution of this Consent. No insurance can be billed on the patient’s behalf without this signed HIPAA consent form, therefore payment in full is required at the time services are rendered. I acknowledge that I received a copy of Ferdos Family Dental Notice of Privacy Practices. I understand that information disclosed to any of the above recipient(s) is no longer proceed by federal or state law and may be subject to re-disclosure by the above recipient. You have the right to revoke this consent in writing. Signature: __________________________________________ Date: __________________________ If you are signing as a personal representative of the patient, describe your relations to the patient and the source of your authority to sign this form: Relationship to Patient: ______________________________ Print Name: ________________________________ Source of Authority: _____________________________________________________________________________