Employer: Employer: Name: Billing Address: Credit Card - Enter card # above (if accepted)

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1 Today's Date: File #. Child's Name: LAST FIRST M I Child's Nickname: Boy Girl Child's Birthdate: School: Child's Home Phone #:( Child's SS#: Child's Address: Age: Grade: HOME ADDRESS CITY STATE ZIP Referred By: (If doctor, please give address & phone number.) Who is accompanying this child today? FULL NAME (IF OTHER THAN PARENT) RELATION TO CHILD Do you have Legal Custody of this Child? Yes No How many Brothers/Sisters? Age(s): MOTHER'S NAME STEP MOTHER GUARDIAN ADDRESS ( CHECK IF SAME AS CHILD'S) HOME ADDRESS CITY STATE ZIP ) HOME PHONE # ( ) WORK PHONE # / / MOTHER'S SOCIAL SECURITY # DATE OF BIRTH MOTHER'S DRIVERS LIC. # Employer: How Long? EMPLOYER'S ADDRESS CITY STATE ZIP FATHER'S NAME STEP FATHER GUARDIAN ADDRESS ( CHECK IF SAME AS CHILD'S) HOME ADDRESS CITY STATE ZIP d Primary Dental Insurance Co. Name: Address: CITY STATE ZIP Phone #: Insured's ID#: Group # (Plan, Local, or Policy #): Insured's Name: Relation: Date of Birth: / / Insured's Employer: Does either policy cover Orthodontics? Yes No Secondary Dental Insurance Co. Name: Address: CITY STATE ZIP Phone #: Insured's ID#: Group # (Plan, Local, or Policy #): Insured's Name: Relation: Date of Birth: / / Insured's Employer: ) HOME PHONE # WORK PHONE # EXT. / / FATHER'S SOCIAL SECURITY # DATE OF BIRTH FATHER'S DRIVERS LIC. # Employer: How Long? EMPLOYER'S ADDRESS CITY STATE ZIP Person ultimately responsible for account Name: Billing Address: SOCIAL SECURITY # STATE RELATION TO CHILD ZIP / / DATE OF BIRTH DRIVERS LIC. # ) WORK PHONE #: EXT. CELL PHONE #: Payment method: Cash Check Credit Card - Enter card # above (if accepted) I hereby authorize assignment of my insurance rights and Initials benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office). Pieusc Continue On Bock

2 40_ Reason for today's visit: Exam Emergency [LI Consultation Is Child in pain? No Yes How Long'? C Please indicate j any of the following problems: Discomfort, clicking or popping in jaw. Lost/Broken Filling(s) Stained teeth Red, swollen or bleeding gums. Teeth grinding Locking Jaw Sensitive tooth, teeth or gums. Ringing in Ears Bad breath Blisters/Sores in or around the mouth. Broken/Chipped tooth Loose tooth Other(s): Does child require pre-medication? Yes No Don't know Previous Dentist: Last Dental exam: / / Last Dental X-rays: / / Times a day child brushes? Times a week child flosses? Is the child's water fluoridated? Yes No How would you rate the child's smile? Best Worst ' \ r t7/ Is Child taking any of the following medications? Pain killers (,INCLUDING ASPIRIN) LI Ritalin Stimulants Blood Thinners Tranquilizers Insulin Muscle relaxers Others: Child's Physician: DOCTOR'S NAME OR CLINIC NAME PHONE# Last Medical Exam: ADDRESS CITY STATE ZIP Does Child have or ever had any of the following diseases, medical conditions or procedures? Y N Heart Murmur Y N Rheumatic fever Y N Artificial Heart Valves Y N Congenital Heart defect Y N Scarlet Fever Y N Surgeries/Operations Y N Cancer/Tumors Y N Chemotherapy Y N Jaw Problems TMJ/TMD Y N Hearing Problems Please list any other medical condition(s) child has or ever had: N Tonsillitis Y N High/Low Blood Pressure Y N Respiratory Problems Y N Hepatitis Y N Asthma/Difficulty Breathing Y N Artificial Bones/Joints/Implants Y N Blood Transfusion(s) Y N Liver/Kidney/Organ Problems Y N Leukemia/Anemia Y N HIV+/AIDS/ARC Y N Diabetes/Hypoglycemia Y N Tuberculosis TB Y N Hemophilia Y N Psychiatric Problems Y N Abnormal Bleeding Y N Hyper Active/ADD Y N Cleft Lip/Palate Y N Fainting/Seizures/Epilepsy Y N Birth Defects Y N Cerebral Palsy Is Child allergic to: Latex Penicillin/Amoxicillin Tetracycline Dental Anesthetics (Novocaine) Aspirin Food allergies Other(s): Please rate the child's general health from 1-10: Does child wear contact lenses? Yes No Has this child ever taken the drug Ritalin? No Yes/How long? Child's Blood type: Does this child do any of the following? Thumb/Finger Sucking Tongue Thrusting/Sucking Heavy Snoring Mouth Breathing Lip Sucking/Biting We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. Signature Date Parent or Guardian J Other. First Impression Forms, Inc FORMS FORM # 1DGC2 Copyright 2010

3 DR. LISA WYATT 5037 VETERANS BLVD STE 3E METAIRIE, LA AGREEMENT FOR TREATMENT IN OUR PRACTICE. 1) A LEGAL GUARDIAN MUST ACCOMPANY THE CHILD (ANYONE UNDER AGE 18) AT ALL TIMES FOR ALL APPOINTMENTS. THIS - MEANS ONLY LEGAL PARENTS, NOT GRANDPARENTS, OR FRIENDS OF PARENTS EVEN IF THE CHILD LIVES WITH THEM. YOU MAY NOT LEAVE WHILE THEY ARE HERE. THIS IS A STATE LAW. WE DID NOT MAKE THE LAW, BUT WE MUST FOLLOW IT. 2) IF YOU MISS THREE APPOINTMENTS WITHOUT A 24 HOUR NOTICE, YOU WILL BE DISMISSED FROM OUR PRACTICE. 3) YOU MUST ARRIVE AT YOUR SCHEDULED APPOINTMENT TIME, THIS IS NOT A CLINIC. IF YOU ARE LATE, ALL THE REST OF THE PATIENTS WILL HAVE TOWAIT BECAUSE OF YOU. 4) IF YOU WANT US TO FILE FOR YOUR INSURANCE FOR YOU, YOU MUST PROVIDE PROOF OF INSURANCE OR PAY AT THE TIME OF YOUR APPOINTMENT. PATIENT SIGNATURE: PARENT SIGNATURE: ( NEEDED FOR ALL MINORS) DATE:

4 LISA WYATT, DDS 5037 VETERANS BLVD STE 3E METAIRIE, LA PH (504) FINANCIAL POLICY AGREEMENT I agree to be responsible to pay in full for all services rendered at time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for delinquent billing fees, legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. Sign Date FINANCIAL POLICY AGREEMENT

5 ACKNOWLEDGEMENT OF RECEIPT: NOTICE OF PRIVACY PRACTICES EFFECTIVE AS OF 03/18/2014 By signing below you acknowledge that you have received, read and understand Lisa Wyatt DDS's (the "Practice") Notice of Privacy Practices ("Notice"). This Notice provides information about how we may use and disclose your Protected Health Information. If you have any question about the Notice, please contact the Practice's Privacy Officer at and ask for Dr. Lisa Wyatt. ACKNOWLEDGEMENT OF RECEPT: I acknowledge receiving, reading and understanding Lisa Wyatt DDS's Notice of Privacy Practices Signature of Individual Date Personal Representative's Section:, hereby certify that I am the personal representative of and warrant that I have the authority to sign this Authorization on the basis of: Signature of Personal Representative Date Internal Use Only In the event acknowledgement cannot be obtained, record below the good faith effort to obtain the acknowledgement and the reason the acknowledgement was not obtained. Effort to obtain acknowledgement In-person request Request via mail (include copy of letter in medical record) Request via (include copy of sent in medical record) Other Reason acknowledgement was not obtained Patient refused to sign Patient unable to sign Patient did not return mail, Other Employee Signature Date

6 Notice of Privacy Practices with Separate AdcnaMedgement Form NOTICE OF PRIVACY PRACTICES Effective as of September 23, 2013 YOUR INFORMATION_ YOUR RIGHTS OUR RESPONSIBILITIES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. YOUR RIGHTS You have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we've shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated YOUR CHOICES You have some choices in the way that we use and share information as we: Tell family and friends about your condition Provide disaster relief Include you in a directory Provide mental health care Market our services and sell your information Raise funds OUR USES AND DISCLOSURES We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers' compensation, law enforcement, and other government requests Respond to lawsuits and legal actions YOUR RIGHTS When it canesto your health information, you 'have certain rights This section explains your rights and some of our responsibilities to help you. 71

7 Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask usto correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but we'll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests. Ask usto limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to chare that information. Get a list of those with whom we've shared information You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose sceneale to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rightsare violated You can complain if you feel we have violated your rights by contacting the Practice in care of the following officer: Privacy Officer, Lisa Wyatt, or you may call (504) You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C , calling , or visiting We will not retaliate against you for filing a complaint. 72

8 YOUR CHOICES For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and dwe will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation Include your information in a hospital directory If you are not able to tell us your preference for exatrple if you are unconscious we nay go ahead and share your information if we believe it is in your best interest. I* may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes Sale of your information Most sharing of psychotherapy notes In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. OUR USESAND DISCLOSURES How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Exarrple A doctor treating you for an iriury asks another doctor about your overall health condition. Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: 1/% use health information about you to manage your treatment and se -vices Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example. I* give information about you to your health insurance plan so it will pay for your services Haw else can we use cr share your health information? We are allowed or required to share your information in other ways usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: ),N, - \ANA goviocr/pro, acx /1 -Lipaw understand giconsumers/index.hunl Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone's health or safety Do research We can use or share your information for health research. 73

9 L Canply with the law We will share information about you if state or federal laws require it, including -with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law. Respond toorgan and tissue donation requests We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers' compensation, law enforcement, and other government requests We can use or share health information about you: For workers' compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. OUR RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: W W W lihs.goviocriprivacv/hipathinderstanding/consumersinoticepplitml. CHANGES TO THE TERM S OF THI S NOTICE We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site (if applicable). ADDITIONAL INFORMATION If you have any questions regarding this notice or the subjects addressed in it, you may contact the following officer: Privacy Officer, Lisa Wyatt, or you may call (504)