First Name Last Name Middle Initial. City State ZIP. Birth Date: SS#: Driver s Lic#: State:

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1 DATE PATIENT ACCOUNT NO PatientRegistration PATIENT S FULL NAME Policy Holder Responsible Party RESPONSIBLE PARTY (if someone other than the patient) First Name Last Name Middle Initial City State ZIP Home Phone ( ) Work Phone ( ) Mobile ( ) Birth : SS#: Driver s Lic#: State: Responsible Party is also: Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder PATIENT INFORMATION City State ZIP Home Phone ( ) Work Phone ( ) Mobile ( ) Sex: Male Female Marital Status: Single Married Separated Divorced Widowed Birth : SS#: Driver s Lic#: State: I would like to receive correspondences via EMPLOYMENT STATUS: Full Time Part Time Unemployed Retired STUDENT STATUS: Full Time Part Time EMERGENCY CONTACT(S): First Contact Name: Medicade ID#: Employer ID#: Carrier ID#: Pref. Dentist Pref. Pharmacy Pref. Hygienist Phone Numbers: Second Contact Name: Phone Numbers: PRIMARY INSURANCE INFORMATION Name of Insured: Relationship to Insured: Self Spouse Child Other Insured SS#: Employer: Insured Birth : Insurance Company: Rem. Benefits Rem. Deductible: SECONDARY INSURANCE INFORMATION Name of Insured: Relationship to Insured: Self Spouse Child Other Insured SS#: Employer: Rem. Benefits Rem. Deductible: Insured Birth : Insurance Company: StevenK. O kamoto Resto R at i v e p Rost h e t i c i m p l a n t d e n t i st Ry A PROFESSIONAL CORPOR ATION

2 Patient Name: MedicalHistory Birth : Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? Yes If yes, please explain: Have you ever been hospitalized or had a major operation? Yes If yes, please explain: Have you ever had a serious head or neck injury? Yes If yes, please explain: Are you taking any medications, pills, or drugs? Yes If yes, please explain: Do you take, or have you taken, Phen-Fen or Redux? Yes If yes, please explain: Have you ever taken Fosamax, Boniva, Adonel or any other medications containing bisphosphonates? Yes If yes, please explain: Are you on a special diet? Yes If yes, please explain: Do you use tobacco? Yes If yes, please explain: Do you use controlled substances? Yes If yes, please explain: WOMEN: Are you Pregnant/Trying to get pregnant? Yes Taking oral contraceptives? Yes Nursing? Yes Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa Drugs Other If yes, please explain: Do you have, or have you had, any of the followlng? AIDSIHIV Positive Yes Cortisone Medicine Yes Alzheimer's Disease Yes Diabetes Yes Anaphylaxis Yes Drug Addiction Yes Anemia Yes Easily Winded Yes Angina Yes Emphysema Yes Arthritis/Gout Yes Epilepsy or Seizures Yes ArtIficial Heart Valve Yes Excessive Bleeding Yes Artificial Joint Yes Excessive Thirst Yes Asthma Yes Fainting Spells/Dizzlness Yes Blood Disease Yes Frequent Cough Yes Blood Transfusion Yes Frequent Diarrhea Yes Breathing Problem Yes Frequent Headaches Yes Bruise Easily Yes Genital Herpes Yes Cancer Yes Glaucoma Yes Chemotherapy Yes Hay Fever Yes Chest Pains Yes Heart Attack/Failure Yes Cold Sores/Fever Blisters Yes Heart Murmur Yes Congenital Heart Disorder Yes Heart Pacemaker Yes Convulsions Yes Heart Trouble/Disease Yes Have you ever had any serious illness not listed above? Yes Hemophilia Yes Radiation Treatments Yes Hepatitis A Yes Recent Weight Loss Yes Hepatitis B or C Yes Renal Dialysis Yes Herpes Yes Rheumatic Fever Yes High Blood Pressure Yes Rheumatism Yes High Cholesterol Yes Scarlet Fever Yes Hives or Rash Yes Shingles Yes Hypoglycemia Yes Sickle Cell Disease Yes Irregular Heartbeat Yes Sinus Trouble Yes Kidney Problems Yes Spina Blfida Yes Leukemia Yes Stomachllntestinal Disease Yes Liver Disease Yes Stroke Yes Low Blood Pressure Yes Swelling of Limbs Yes Lung Disease Yes Thyroid Disease Yes Mitral Valve Prolapse Yes Tonsillitis Yes Osteoporosis Yes Tuberculosis Yes Pain in Jaw Joints Yes Tumors or Growths Yes Parathyroid Disease Yes Ulcers Yes Psychiatric Care Yes Venereal Disease Yes Yellow Jaundice Yes If yes, please explain: Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing Incorred information can be dangerous to my (or patienfs) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient, Parent, or Guardian

3 DentalHistory What is the reason for your visit today? of Last Dental Visit Last Dental Cleaning Last Full Mouth X-rays What was done at your last dental visit? Dentist s Name State Zip Telephone How often do you have dental examinations? How often do you brush your teeth? How often do you floss? What other dental aids do you use? (electric toothbrush, toothpick, etc.) Do you have any dental problems now?yes If yes, please describe: Are any of your teeth sensitive to: Hot or cold? Yes Sweets? Yes Biting or Chewing? Yes Have you noticed any mouth odors or bad tastes? Yes Do you frequently get cold sores, blisters or any other oral lesions?.... Yes Do your gums bleed or hurt? Yes Have your parents experienced gum disease or tooth loss? Yes Have you noticed any loose teeth or changes in your bite? Yes Does food tend to become caught in between your teeth? Yes If yes, where? Yes Do you: Clench or grind your teeth while awake or asleep? Yes Bite your lips or cheeks regularly? Yes Hold foreign objects with your teeth? Yes Mouth breathe while awake or asleep? Yes Have tired jaws, especially in the morning? Yes Smoke/chew tobacco? Yes Have you ever had: Orthodontic treatment? Yes Oral surgery? Yes Periodontal treatment? Yes Your teeth ground or the bite adjusted? Yes A bite plate or mouth guard? Yes A serious injury to the mouth or head/? Yes If yes, please describe, including cause Have you experienced: Clicking or popping of the jaw? Yes Pain? (joint, ear, side of face)? Yes Difficulty in opening or closing the mouth? Yes Difficulty in chewing on either side of the mouth? Yes Headaches, neckaches or shoulder aches? Yes Sore muscles (neck, shoulders)? Yes Are you satisfied with your teeth s appearance? Yes Would you like to keep all of your teeth all of your life? Yes Do you feel nervous about having dental treatment? Yes If so, what is your biggest concern? Have you ever had an upsetting dental experience? Yes If yes, please describe Is there anything else about having dental treatment that you would like us to know? Yes If yes, please describe: 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 health care provider or agency who may release such information to you. I will notify the doctor of change in my health or medication. Patient/Guardian Signature History Review Dentist s Signature

4 HipaaPrivacyRule OF PATIENT AUTHORIZATION AGREEMENT Steven K. Okamoto, DDS, Torrance, California Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations ( (a)) I,, (patient s name) understand that as part of my healthcare, Steven K. Okamoto, DDS, Torrance, California originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment; A means of communication among the health professionals who may contribute to my healthcare; A source of information for applying my diagnosis and surgical information to my bill; A means by which a third-party payer can verify that services billed were actually provided; A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I have been provided with a copy of the tice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review Steven K. Okamoto, DDS, Torrance, California s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. PRIVACY RULE OF PATIENT CONSENT AGREEMENT Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations ( (a)) I understand that: I have the right to review Steven K. Okamoto, DDS, Torrance, California s tice of Information practices prior to signing this consent; This Steven K. Okamoto, DDS, Torrance, California, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I ve provided if requested; I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that Steven K. Okamoto, DDS, Torrance, California is not required by law to agree to the restrictions requested. I may revoke this consent in writing at any time, except to the extent that Steven K. Okamoto, DDS, Torrance, California, has already taken action in reliance thereon. Signature of Individual or Legal Representative: Printed Name of Individual or Legal Representative: : Continue on back

5 HipaaPrivacyRule RECEIPT OF NOTICE OF PRIVACY PRACTICE WRITTEN ACKNOWLEDGEMENT FORM Steven K. Okamoto, DDS, Torrance, California Acknowledgement of Receipt of Information Practices tice ( (a)) I,,(patient s name) understand that as part of my healthcare, Steven K. Okamoto, DDS, Torrance, California originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that Steven K. Okamoto, DDS, Torrance, California s tice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that: I have the right to review Steven K. Okamoto, DDS, Torrance, California s tice of Privacy Practices prior to signing this acknowledgement; This facility reserves the right to change their tice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested. Signature of Individual or Legal Representative: Printed Name of Individual or Legal Representative Witness: : FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our tice of Privacy Practices, but it could not be obtained because: Individual refused to sign Communication barrier prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify) HIPAA Officer

6 Authorization for the Release of Dental Records California ReleaseofDentalRecords AUTHORIZATION I hereby authorize information in the dental record of Steven K. Okamoto, DDS to release the, DDS to release the (patient s name) to (name of dentist, physician, clinic, or patient s representative) (address) Any and all information may be released including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any, except as specifically provided below. This authorization is effective now and will remain in effect until I understand that I may receive a copy of this authorization. (date). Signature If not signed by the patient please indicate relationship: parent or guardian of minor patient guardian or conservator of an incompetent patient beneficiary or personal representative of deceased patient NOTE: This authorization is intended to comply with applicable state laws. It is not intended as a Consent or Authorization for the use and disclosure of Protected Health Information (PHI) under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or its implementing regulations. The medical provider to whom this authorization is directed should ensure that he or she is in compliance with applicable HIPAA requirements before releasing the requested records. CAUTION: If you intend to use the requested information for any purpose other than providing medical treatment, 45 CFR Section requires that you make reasonable efforts to limit your request for PHI to the minimum necessary to accomplish the intended purpose of the request. To be valid, an authorization must be clearly separate from other language on a page and executed by a signature which serves no purpose other than to execute the authorization. It can either be handwritten by the person who signs it or in typeface no smaller than 8 point (this is 8 point). Copy to be placed in patient s chart Place a copy in the patient s chart.