Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:

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1 M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip: Phone Home: Work: Cell: Person responsible for payment of account: Phone: Relation: Person to contact in case of emergency: Phone: Relation: Referred by: Physician name: Dentist s name: Physician s phone: II. DENTAL INSURANCE INFORMATION: Do you have dental insurance? Yes No If Yes: Self? Spouse? Dual insurance? Would you like us to assist you in the submission of your insurance claims? Yes No Primary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number: Group or company name: Patient s relationship to subscriber: Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number: Group or company name: Patient s relationship to subscriber: I understand that I am responsible for all costs of dental treatment. I hereby authorize the release of any information, including records of examination and treatment, to my insurance company. I understand that I am responsible for payment for services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the above named dentists of the group insurance benefits otherwise payable to me. SIGNATURE: DATE: III. DENTAL QUESTIONNAIRE: Reason for Referral / Chief Complaint: Yes No Are you dissatisfied with your chewing ability? Yes No Are you having pain in your mouth? Yes No Are you dissatisfied with the appearance of your teeth? Yes No Do you clench or grind your teeth? Yes No Do you have a family history of periodontal disease? Yes No Have you had periodontal treatment? Do you have or have you recently had: Yes No Bleeding gums? Yes No Teeth drifting? Yes No Unpleasant odor or taste in your mouth? Yes No Loose teeth? Yes No Sensitive teeth? Yes No Food caught between teeth? How often do you brush your teeth? What else do you use to clean your teeth? Type of toothbrush: (1) Manual Electric (2) Soft Medium Hard Don t know When did you have your last teeth cleaning? Have you had gum or oral surgery in the past? Yes No Please rate your level of apprehension towards dental treatment: None Mild Moderate Severe Extreme

2 M a u r i c i o R o n d e r o s, D D S, M S, M P H H EALTH H I S T O R Y Patient Name: Birth date: I. CIRCLE APPROPRIATE ANSWER: Yes No Is your general health good? Please rate your health status: Excellent Good Fair Poor Yes No Has there been a change in your health within the last year? Yes No Have you been hospitalized or had a serious illness in the last three years? If YES, explain: Yes No Is a physician currently treating you? For what? Date last medical exam: Yes No Are you in pain or discomfort at the present time? II. HAVE YOU EXPERIENCED: Yes No Chest pain (angina)? Yes No Sinus problems? Yes No Headaches? Yes No Swollen ankles? Yes No Bleeding problems? Yes No Fainting spells? Yes No Shortness of breath? Yes No Bruising easily? Yes No Seizures? Yes No Recent weight loss, fever? Yes No Frequent vomiting, nausea? Yes No Frequent urination? Yes No Persistent cough? Yes No Dizziness, ringing ears? Yes No Dry mouth? Yes No Allergies to medications, foods, latex, others? If Yes, please list: III. DO YOU HAVE OR HAVE YOU HAD: Yes No Heart disease? Yes No Tuberculosis (TB)? Yes No Arthritis, rheumatism? Yes No Heart attack? Yes No Emphysema? Yes No Venereal diseases Yes No Heart defects? Yes No Other lung diseases? Yes No HIV+ status, AIDS? Yes No Heart murmurs? Yes No Hepatitis, other liver disease? Yes No Eye diseases? Yes No Arteriosclerosis? Yes No Kidney problems? Yes No Glaucoma? Yes No Rheumatic fever? Yes No Stomach or GI ulcers? Yes No Skin diseases? Yes No Stroke? Yes No Other stomach problems? Yes No Anemia? Yes No High blood pressure? Yes No Thyroid, adrenal disease? Yes No Herpes? Yes No Asthma? Yes No Tumors, cancer? Yes No Diabetes? III. DO YOU HAVE OR HAVE YOU HAD: Yes No Radiation treatment? Yes No Prosthetic heart valve? Yes No Psychiatric care? Yes No Chemotherapy? Yes No Artificial joint? Yes No Hospitalizations? Yes No Pacemaker? Yes No Other implanted devices? Yes No Surgeries? IV. DO YOU USE OR DO YOU TAKE: Yes No Recreational drugs? Yes No Prescription drugs, medications, over-the-counter medicines (including Aspirin), natural remedies? If YES, please list: Yes No Do you smoke cigarettes? If YES, please list the approximate number of cigarettes that you smoke or used to smoke and the total Yes No Are you a former smoker? number of years smoking: cigarettes per day, years Yes No Do you use tobacco in any form other than smoking? If Yes, please explain: V. WOMEN ONLY: Yes No Are you or could you be pregnant? Yes No Are you nursing? Yes No Use birth control pills? IV. ALL PATIENTS: Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain: I have answered every question completely and accurately. I will inform my dentist in this office of any change in my health and/or medications. Patient s signature: Date: Notes:

3 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 4/14/03, and will remain in effect until we replace it. 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: 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 (e.g., to your insurance company). 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: Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. In addition to our use of your health information for treatment, payment or healthcare operations, you have the right 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 permitted by your authorization while it was in effect. 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 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 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: authorization. We will not use your health information for marketing communications without your written Required by Law: We may use or disclose your health information when we are required to do so by law. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, letters, or s). Post-treatment follow-up: We may use or disclose your health information to assess your health status or your response after receiving treatment. Post-treatment follow-ups may be conducted via voic messages, postcards, letters, s, etc.

4 PATIENT RIGHTS Access: You have the right to look at or get copies of your health information. You must make a request in writing using the contact information listed at the end of this Notice to obtain access to your health information. If you prefer, we will prepare a summary or an explanation of your health information. We may charge you a reasonable cost-based fee for expenses such as copies and staff time. 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 alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative 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 alternative 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. Contact: Mauricio Ronderos Telephone: Fax: Address: 358 Marine Parkway Ste 300, Redwood City, CA 94065

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES PATIENT INFORMATION Name: Address: Telephone: I,, acknowledge that I have received a copy of this office s Notice of Privacy Practices. Signature: Date: If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name: Relationship to Patient: