PATIENT INFORMATION. Address City State Zip _. Date of Birth _ Social Security No. _. Work _ Cell. Employer ~ Occupation _

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1 PATIENT INFORMATION Today's Date First Name I prefer to be called (nickname, etc.) Middle Initial Last Name Male Female Married Single Child Other...,-- Address City State Zip Date of Birth Social Security No. Home Phone Work Cell Employer ~ Occupation Whom may we thank for referring you? Primary carrier DENTAL INSURANCE Insurance Co. Name Insurance Co. Phone Address(StreetCity,State,~p) Group No. (Plan or Policy No.) Insured's I.D. No. Insured's Name Relationship to Patient Date of Birth Insured's Social Security No. Insured's Employer Name Is insured a patient in our office? Secondary carrier Insurance Co. Name Insurance Co. Phone Addreg(Str~tOty,~~~~p) Group No. (Plan or Policy No.) Insured's I.D. No. Insured's Name Relationship to Patient Date of Birth Insured's Social Security No. Insured's Employer Name Is insured a patient in our office? If patient is a minor, name of parent or legal guardian and relationship Is this parent or legal guardian currently a patient in our office? I understand Payment is due in full at the time of treatment that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency that may rele-ase such information to you. I will notify the dentist of any changes in my health or medication. Signature Date Person to Contact in case of emergency Name Relationship HomePhone Cell

2 Reasonfor today's visit Are you currently in Pain? Yes No If so, please describe: Dental History Do you have any dental problems now? Yes No If so, please describe: ---: Have you ever had trouble with previous dental treatment? Yes No If so, please describe: Date of last dental exam Date of last cleaning Date of last X-rays Procedure(~doneatla~dentalv~~ Previous dentist's name City State Phone No. How often do you have dental examinations? How often do you brush your teeth? How often do you floss? What type of bristles do you use? Hard Medium Soft What other dental aids do you use?(electric toothbrush, toothpick, etc.) Do you require antibiotics before dental treatment? Do your gums ever bleed? Are your teeth sensitive to heat/cold? Do you clench or grind your teeth? Have you ever had: Periodontal disease/gum treatment? Discomfort in your jaw joint (TMJ/TMD)? A bite plate or mouth guard? Serious injury to the mouth or head? Isthere anything else about your past dental treatment(s) that you would like usto know? Medical History Haveyou been hospitalized or under the care of a medical doctor during the past 2 years? If yes,for what? Hospital or Physician's Name Phone Hospital or Physician'sCity State MEDICATIONS Please list current medications including aspirin or over-the-counter meds: Medication/ Reasonfor taking Medication/ Reasonfor taking

3 MedicalHistoryContinued... Joint Replacement- Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Date: If yes, have you had any complications? Are you taking or have you ever taken alendronate (Fosamax) or risedronate (Actonel) for osteoporosis? If yes, date last taken: ~ Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer? Date Treatment began: Allergies- Are you allergic to or have you had a reaction to: Local anesthetics Penicillin or other antibiotics Sulfa Drugs Metals Iodine Other Yes/NO Aspirin Barbiturates, Codeine or other Latex (rubber) Hay Fever/Seasonal sedatives, or sleeping pills narcotics -, --- Artificial {prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart Osteoporosis Congenital heart disease (CHD) Sleep disorder Cancer/Chemothera py/rad iation Cardiovascular disease Mitral valve prolapsed Angina Pacemaker Arteriosclerosis Rheumatic fever Congestive heart failure Rheumatic heart disease Damaged heart valves Abnormal bleeding Heart attack Anemia Heart murmur Blood transfusion Low blood pressure if yes, date: High blood pressure Hemophilia Other congenital heart defects AIDS or HIV infection Arthritis Autoimmune disease Hepatitis, jaundice or liver disease Epilepsy Asthma Fainting spells or seizures Emphysema Tuberculosis Diabetes Severe headaches/migraines Ulcers Sexually transmitted disease Thyroid problems Stroke Do you use controlled substances (drugs) Do you use tobacco (smoking,snuff,chew) Do you drink alcoholic beverages Women Only- Are you pregnant? Number of Weeks: Taking birth control or hormonal replacement?.please list any disease, condition, or problem not listed above that you think I should know about? Nursing? I' Note: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a -truthfulhealth history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any" about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in - the completion of this form. Signatureof Patient/legal Guardian: Date: r certify

4 ~'--- PLEASE READ CAREFULLY'!' PATIENT CONSENT FORM I, do hereby give my legal consent to Ritter Family Dentistry to perform the services which have been explained to me on myself my child my ward with the exception of. I have also given a true and accurate medical history to Ritter Family Dentistry because I understand that medical problems past or present, prescribed medication, and over the counter medication can have dangerous consequences during and after dental treatment. I understand that drugs used in the dental office can have adverse effects such as allergic reactions, drowsiness, and stomach upset. I also understand the use of anesthetic agents embodies a certain risk. I understand that during extractions of lower teeth a jaw fracture may occur or temporary to permanent numbness of the lip or tongue may occur. Extraction of upper teeth may result in an exposure of the maxillary sinus which can be difficult to close. Existing restorations may be damaged, and infection may result. As with all dental treatment cuts and abrasions may occur in the course of treatment. I understand that root canal therapy is not always successful, especially with badly infected teeth and extraction may be necessary after root canal therapy is done. I understand that any filling, crown, brldge, or any other restoration may turn out to be more complex than originally anticipated and require more complex therapy. An example is a tooth which has a cavity deeper than expected may require a root canal and a crown rather than a filling. I understand that all efforts will be made to insure the occlusal harmony of restorations but that sometimes temporomandibular joint pain may occur as a result or from other causes., The usual complications which may result from my treatment have been explained. I realize that I may ask as many questions I want to and I may refuse any treatment recommended. I accept that complications can arise from treatment and medication beyond the dentist's control and that good oral health is also my responsibility and often failure of dental therapy is due to patient neglect. I accept that these and other complications may result from my treatment and" do not and will not hold Ritter Family Dentistry and his staff liable for complications which occur beyond their control. I understand that I may strike out any sentence or paragraph with a pen which I do not agree with. I will write any comments pertaining to my consent here: I may cancel this consent at any time after a specific procedure is completed for future treatment but not for treatment already performed. Signed Date

5 Ritter Family Dentistry ACKNOWLEDGEME-NT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse to Sign This Acknowledgement* I,, have received a copy of this office's Notice of Privacy Practice. Please Print Name: Signature: ~ - Date: For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual -- I refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)

6 Ritter Family Dentistry 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 Notice while it is In effect. This Notice takes effect 2/2/04, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make 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 atthe end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION: We use and disclose health information about your treatment, payment, and heattncere 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, conduction training programs, accreditation, certification, licensing or credentiallng 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 lntcrmattcn.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 permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. 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 health care, but only if you agree that we may do so. Persons Involved In Care: We may USeor disclose health information to notify, or assist in the notification of (including identifying or locating).a family member, your personal representative or another person responsible for your care, of your location, 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 or 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-ravs, or other similar forms of health information. Marketing Health-Related Services: We will use your health information for marketing communications without your written authorization. Required By Law: We may use or dlsclose 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 safety or the health or safety of others.