PATIENT INFORMATION DENTAL INSURANCE MEDICAL HISTORY

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Alyson Lisa Russell
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1 TIGER Tiger ADVANCED TIGER Smile SMILE Dental DENTAL DENTAL SMILE DENTAL CONCEPTS PLEASE GIVE THE STAFF A CURRENT COPY OF YOUR INSURANCE CARD ALONG WITH A VALID DRIVER S LICENSE. PATIENT INFORMATION Patient Name Preferred Name Married Single Other Address DOB SSN City Drivers License # State Zip Home# Cell# Work# Fax# Employer Emergency Contact Name Home# Cell# How did you hear about us? Whom may we THANK for referring you to our office? DENTAL INSURANCE Subscribers Name Is patient covered by secondary insurance? Yes No Relationship Subscribers Name Birthday SSN Relationship Insurance Co. Birthday SSN Group # Policy # Insurance Co. Phone # Group # Policy # Employer Phone # Employer MEDICAL HISTORY Are you under the care of a physician now? YES/NO Physician s Name Have you had serious head or neck injuries? YES/NO Name of Clinic Are you on a special diet? YES/NO City/State Phone# Have you been hospitalized or had an operation within the past five (5) years? YES/NO If so, what was the problem? Have you had abnormal bleeding associated with previous extractions, surgery, or trauma? YES/NO Do you have to pre- medicate before dental visits? YES/NO Are you allergic or have you reacted adversely to: Local anesthetics Aspirin Penicillin or other antibiotics Iodine Sulfa drugs Codeine or other narcotics Latex Metal Barbiturates, sedatives, or sleeping pill Other (PLEASE LIST) Are you taking any medications, pills or drugs? YES/NO If yes, please list them here (including any dietary supplements) Have you EVER taken ANY type of medication by mouth or by injection for bone density? YES/NO (Please include name of medication, date when taken, and Doctor s name)

2 PLEASE MARK ALL THAT APPLY X X X X Angina/Chest Pain Arthritis/Gout Artificial Joint/Joint Replacement Asthma Bacterial Endocarditis Bactrim Allergy Bisphosphonates(BONE DENSITY) Cancer/Tumors Chemotherapy Convulsions/Epilepsy Coumadin or Blood Thinner Diabetes Emphysema/Breathing Problems Enlarged Lymph nodes Excessive Bleeding Excessive Thirst Fainting/Dizziness Glaucoma Head Injuries Heart Attack Heart Disease Heart Murmur Heart Stent Heart Surgery Heart Transplant/Valve Hemophilia Hepatitis/any form High Blood Pressure Inflammatory Disease Jaundice Kidney Disease/Dialysis Leukemia Liver Disease Low Blood Pressure Lung Disease Mental/Nervous Disorders Mitral Valve Prolapse PRE- MED Pacemaker Pain in Jaw Joint Parathyroid Disease Penicillin Allergy Psychiatric Care Pregnancy Radiation Treatment Recurrent Illnesses Renal Disease Sickle Cell Disease Rheumatic/Scarlet Fever Rheumatism Shunt Sinus Problems Rheumatic heart disease Stomach Ulcers Stroke Thyroid Disease Transplant/any type Tuberculosis Ulcers/Cold Sores/Fever Blisters Venereal Disease Coronary insufficiency, coronary Allergy Persistent cough or cough up Immune system disorders occlusion, arteriosclerosis blood (including AIDS, HIV, ARC) Stomach Problems Hives or skin rash Blood disorders such as anemia Other Have you ever tested POSITIVE for the AIDS virus? YES/NO Have you ever had surgery or x- ray treatment for a tumor, growth, or other condition? YES/NO Do you have any disease, condition or problem not listed that you think we should know about? YES/NO If so, please explain Do you use tobacco products? YES/NO If so, how much per day and what? Do you use any alcohol products? YES/NO If so, how much per day/week/month and what Do you use any caffeinated products (coffee, tea, chocolate, etc.) YES/NO If so, how much per day and what Are you experiencing stress or pressure in your work or at home? YES/NO WOMEN Are you taking birth control or hormone therapy? YES/NO Are you pregnant or trying to get pregnant? YES/NO If so, which trimester? Are you nursing? YES/NO Are you on contraceptives? YES/NO Sign X Print X (circle one) Adult Patient Father of Patient Mother of Patient Legal Guardian Date X

3 CONSENT FOR DENTAL TREATMENT AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION There are now legal requirements for us to obtain your consent for dental treatment. Please ask us about anything you do not understand and we will be pleased to explain anything and/or answer any of your questions. There are risks associated with any dental treatment. This includes the administration of any local or general anesthetic agent, analgesic agent(s) to produce conscious sedation, and/or premedication prior to dental care being rendered. Some of these risk and/or complications are, but are not limited to, the following 1. Severe swelling and bruising 11. Pain 2. Paraesthesia (permanent or transient numbness of the cheeks, gums, 12. Breakage of root(s) and retained teeth, lips, tongue, chin, and face) root fragments 3. Loss of taste 13. Loss of and/or damage to 4. Swallowing and/or aspiration of objects adjacent teeth and bone 5. Allergic reaction to drugs 14. Sinus involvement 6. Dry socket 15. Trismus (jaw pain or difficulty 7. Failure of treatment to accomplish it s purpose opening mouth) 8. Heavy bleeding 16. Further treatment and/or 9. Instrument breakage surgery 10. Infection 17. Brain damage/death I acknowledge that I have read, or that it has been read to me, and I understand the information contained on this consent form. I was given an adequate opportunity to ask any questions and that all questions that were asked were answered. I hereby authorize and direct Dr. Neil Oza and/or Dr. Cecilia Luong and/or associates, hygienists, assistants of his/her choice to render dental treatment to. The treatment rendered may be either diagnostic, surgical, and/or any other form of treatment for which Dr. Neil Oza, Dr. Cecilia Luong, and Dr. Reena Oza is/are licensed to perform. This consent form will remain valid until revoked by me in writing. Date Signature of patient or guardian

4 I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in that treatment directly and indirectly Obtain payment from third- party payers Conduct normal healthcare operations such as quality assessments and physician certifications I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name: Signature: Relationship to the Patient: Date:

5 Neil S. Oza, DDS and Cecilia Luong, DDS Acknowledgement of Receipt of Notice of Privacy Practices This form illustrates how a dental practice could obtain acknowledgement of receipt of its Notice of Privacy Practices or document its good faith effort to obtain that acknowledgement. Advanced Dental Concepts (Name of Practice) *You May Refuse to Sign This Acknowledgment* I have received a copy of this office s Notice of Privacy Practices. 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 refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations. 2010, 2013 American Dental Association. All Rights Reserved.

6 ADVANCED DENTAL CONCEPTS Patient Name: Guarantor Name: (Person responsible for payment) Address: Acct # Phone # Dental Treatment Recommended: (Date) TRUTH- IN- LENDING STATEMENT FINANCIAL ARRANGEMENT GENERAL I,, agree to the following financial arrangements for all treatment and services pro- (Guarantor for above patient) vided at New Patient visits, Recall appointments, Emergency visits and all other Dental Treatment Plans from this day forth. NO INSURANCE COVERAGE All services provided will be paid in full at the time of appointment. In the event there would be a balance due I will abide by the agreements set forth to handle the amount due. I understand that any payment that is 30 days past due is subject to collection fees and interest charges of 1.5% per month on the unpaid balance. I also agree to pay such fees incurred for collection of such account including but not limited to collection agency fees or court costs. INSURANCE Our office will prepare any necessary forms to assist you in making claims to the Insurance Company. However, our office cannot render services on the assumption that our fee will be paid by your insurance company. I agree to pay the estimated co- pay on all procedures on the day of treatment. In the event that insurance is filed for any of the services, I agree to pay in full any amount that is not paid or covered by insurance within 30 days of notification of said balance. In the event that the insurance company does not pay Dr. Neil Oza or Dr. Cecilia Luong the amount expected due by the insurance company within 45 days, I agree to pay in full any amount that is not paid within 30 days of notification of said balance. I understand that any payment that is 30 days past due is subject to collection fees, and interest charges of 1.5% per month on the unpaid balance. I also agree to pay such fees incurred for collection of such account including but not limited to collection agency fees or court costs.

7 OFFICE POLICIES Thank you for giving us the opportunity to join with you in caring for your dental needs. We want to take this time to welcome you to our practice and introduce you to our policies. All of our office policies are created so that our patients can benefit from a well- organized visit. Your agreement with our office policies can lower the cost of your dental visits and minimize waiting times. APPOINTMENT AGREEMENT Appointments and Appointment Times must be kept by our patients and parents in order for our Appointment System to operate successfully. If you need to cancel or change an appointment, we require a 48- hour notice (2 business days). A minimum of $50 will be charged if you do not show up for your appointments or if you do not give us a 48- hour notice. Sign X CONFIMATION POLICY We always wish to give you the most convenient appointment available. Confirming appointments will greatly help us to do this. You will receive a telephone call from our office verifying your appointment time one (1) day before the scheduled appointment. Please return our call if a message is left so that your appointment can be considered confirmed. We must receive a confirmation from you in the form of verbal, text, or by the end of the day or your reserved appointment time may be cancelled. DENTAL WORK We make every effort to keep our fees for dental services as reasonable as possible. You are expected to pay for dental work at the time of services. If the treatment plan requires several visits, you will be given an estimate and offered to make financial arrangements by our patient consultant. If you have insurance, you are responsible to pay your in office co- pay at that time. Appointments for dental work may vary in frequency, length of time, and time of day. We know that all patients are not alike, therefore, we tailor our services and time to you as an individual. The time slot set up for you is based on you or your child s needs. We require a minimum deposit of 10% to be paid before scheduling an appointment for dental work. Sign X FINANCIAL AGREEMENT You are required to pay at the time of service. Our office will file claims with your insurance carrier. We will contact your insurance carrier on the day of your visit and verify your coverage. However, we cannot guarantee that your insurance can be verified even though we will make all attempts to do so. We do require payment in full without insurance verification or if the insurance does not guarantee payment to us. There is an in- office co- pay (usually $40) once insurance is verified. Insurance coverage varies a great deal among different policies. Know your policy and financial obligation. You are ultimately responsible for your dental fees, not your insurance company. Sign X I have read, understand, and agree to Advanced Dental Concepts office policies. X Signature of Patient (in the case of a child Parent/Guardian) Date Patient s Name

Patient Signature (parent if minor): Date:

Patient Signature (parent if minor): Date: Patient Information Patient Name Mailing Address City State Zip: Home Phone: Cell Phone: Work Phone: Email: Birth Date: / / Age: Sex: Male Female Social Security: Drivers License: Emergency Contact: Phone