If the patient Is a child

Dental History

Level of anxiety about seeing the dentist: (least) 1 2 3 4 5 (most)

Have you ever had:

Medical History

Women only:

Indicate which of the following you have had or have at present:

Please list any serious medical condition(s) that you have ever had not listed above:

Are you aware of having an allergic (or adverse) reaction to any of the following:

Person Resposible For Payment

Who will pay this account?

Employment Information

Insurance Information

Primary

Secondary

Consent for Services

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.

All emergency denial services, or any dental services performed without previous financial amangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patent and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannol render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 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.

In consideration for the professional services rendered to me, or al my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing of credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing. within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further larm or condition and i further agree to pay all costs and reasonable attomey lees if sult be instituted hereunder.

I grant my permission to you or your assignes, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Our Policy on Finances

Thank you for choosing us as your dental care provider. We are committed to your successful treatment. Please understand that payment of your bill is considered part of your treatment. This is a statement of our Financial Policy, which we require that patients read and sign before any treatment.

FULL PAYMENT IS DUE AT TIME OF SERVICE.

WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD/AMERICAN EXPRESS.

WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL

Insurance-We will accept assignment of your insurance benefits. However, depending upon the terms of your coverage, we require that 10-50% of the bill be paid at time of service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information and an original claim form. 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 necessary under your dental insurance plan. We will make all attempts to advise you of any non-covered treatments and the percentage of such treatments that will be your personal responsibility.

Usual and Customary Rates-Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. This specifically applies to insurance that pays on fee schedules.

Missed Appointments-Please cancel appointments you are unable to keep at least 24 hours in advance. Be aware that it is our policy to charge for missed appointments at the rate of a normal office visit if not cancelled as requested. Please help us serve you better by keeping your scheduled appointments.

I recognize that any of the fees charged to me by you for your services are primarily my responsibility despite any insurance coverage. Should the insurance fail to pay. I understand that I will be personally responsible for the payment of those fees. I further understand that should I fail to pay any fees due to your office and you refer my account to a lawyer, I will pay a lawyer's fee equal to 33 1/3% of the balance due plus any and all court costs and other costs.

I understand that if I do not abide by the terms and conditions of the payment requirements concerning fees for services billed to me that I will be charged 1.5% interest per month on any outstanding unpaid balance.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health Information. We must follow the privacy practices that are described in this Nolice while it is in effect. This Nolice takes effect (MM/DD/YR), and will remain in effect until we replace il.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permilled by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Nolice effective for all health information that we maintain, including health information wo created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations Include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health Information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permilled by your authorization while it was in effect. Unless you give us a willen authorization, we cannot use or disclose your health information for any reason except those described in this Nolice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health Information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health Information to notify, or assist in the notification of (Including Identifying or localing) a family member, your personal representative or another person responsible for your care, of your locallon, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your Incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health Information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best Interest in allowing a person to pick up filled prescriptions, medical supplies, x- rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your wrillen authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes We may disclose your health information to the extent necessary to avert a serious threat to your health or salely or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or lellers).

PATIENT,RIGHTS

Access: You have the right to look at or gel copies of your health information, with limited exceptions. You may request that we provide coples in a formal other than photocopies. We will use the formal you request unless we cannol practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as coples and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0. for each page, per hour for staff time to locate and copy your health Information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a lee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health Information by alterative means or to alternative locations. (You must make your request in writing.) Your request must specify the allemalive means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health Information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

QUESTIONS AND COMPLAINTS

If you want more Information about our privacy practices or have questions or concerns, please contact us.

if you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health Information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at allernative locations, you may complain to us using the contact Information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.