PATIENT REGISTRATION & HISTORY

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PATIENT INFORMATION Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT, PLEASE COMPLETE: FULL-TIME PART-TIME PARENT/GUARDIAN NAME(S) SCHOOL/LOCATION Patient Date of Birth: E-Mail: Patient SSN: ADDRESS LINE 1 HOME: ADDRESS LINE 2 CELL: OTHER: CITY ST ZIP CODE PAGER: FAX: Referral? Yes No Referred by: EMERGENCY INFORMATION In case of emergency, please provide information for the nearest relative or designated contact person not at the patient s address: Tel: NAME Employer: E-Mail: Subscriber: Subscriber Date of Birth: Subscriber Employer: RELATIONSHIP EMPLOYMENT INFORMATION Occupation: ADDRESS LINE 1 WORK: X DIRECT: ADDRESS LINE 2 OTHER: PAGER: CITY ST ZIP CODE FAX: INSURANCE INFORMATION LAST FIRST MI PREFERRED TITLE Subscriber SSN: Patient Relationship to Subscriber: SELF SPOUSE CHILD OTHER PRIMARY INSURANCE CARRIER: Group/Policy No.: ID No.: CITY ST ZIP CODE SECONDARY INSURANCE CARRIER: Group/Policy No.: ID No.: CITY ST ZIP CODE TEL: TOLL-FREE: FAX: TEL: TOLL-FREE: FAX: PATIENT REGISTRATION & HISTORY 1/6

Dentist: Clinic/Facility: PREVIOUS DENTIST INFORMATION Telephone: Reason for changing: CITY ST ZIP CODE ORAL HEALTH: EXCELLENT GOOD FAIR POOR Date of Last Dental Visit: DENTAL HISTORY Treatment Type: Would you like to have a VisiLite oral cancer screening? Y N *Note: Some insurance plans do not cover this service; please check your plan documents for details. Y N Are you currently having dental discomfort? If yes, explain: Y N Any unhappy/unpleasant dental experiences? If yes, explain: Y N Any injuries to mouth/teeth/head? If yes, explain: Y N Any missing teeth other than wisdom teeth or orthodontic extractions? Y N Have missing teeth been replaced? Y N Orthodontic appliances now or in the past? Y N Gums bleed when brushing or flossing? Y N Concerned about gum disease? History of gum disease? Y N Y N Any concerns about the appearance of your teeth? Y N Does it hurt to bite or chew? Y N Do you clench or grind your teeth? If so, do you wear a night guard or splint? Y N Y N Do you want to become a regular continuing care patient in our practice? Y N Do you want your mouth properly restored and pain free? Y N Does any type of dental treatment make you nervous? If yes, please explain below: The most important concerns regarding my dental treatment are: What factors are most important for your satisfaction with our office? Any additional concerns/comments? CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS: Y N Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.) Y N Any unusual speech habits? If yes, explain: Y N Any lost teeth? If yes, list: Y N Does the patient receive assistance with brushing and flossing? If yes, how often? Physician: Clinic/Facility: PRIMARY PHYSICIAN INFORMATION Telephone: PATIENT REGISTRATION & HISTORY 2/6

MEDICAL HISTORY GENERAL HEALTH: EXCELLENT GOOD FAIR POOR Y N Under a physician s care now? Y N Any hospitalization in the past 5 years? Y N Any serious illnesses/surgeries? Y N Use tobacco in any form? If Yes, Type: Y N Is pre-medication required before dental visits due to heart condition or artificial joint? Y N Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section. FEMALE PATIENTS: Y N Currently nursing? Y N Currently pregnant? Due Date: Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients? Y N If yes, please describe: Is there anything important about your medical condition we have not asked? Y N If yes, please describe: ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): NONE ACID REFLUX BULIMIA HEARING PROBLEMS PSYCHIATRIC TREATMENT ADHD CANCER/MALIGNANCY HEART ATTACK RADIATION/CHEMO AIDS/HIV CEREBRAL PALSY HEART DISEASE RESPIRATORY DISEASE ANEMIA CHEMICAL DEPENDENCY HEART MURMUR RHEUMATIC FEVER ANOREXIA CHICKEN POX HEPATITIS SINUS PROBLEMS ANXIETY CONVULSIONS HIGH BLOOD PRESSURE STROKE ARTIFICIAL HEART VALVE DEPRESSION KIDNEY DISEASE THYROID CONDITION ARTIFICIAL JOINTS DIABETES LIVER PROBLEMS TUBERCULOSIS ARTHRITIS DIZZINESS/FAINTING MITRAL VALVE PROLAPSE ULCERS ASTHMA EPILEPSY/SEIZURES MONONUCLEOSIS VENEREAL DISEASE AUTISM/ASPERGER S FREQUENT EAR INFECTIONS PACEMAKER BLEEDING DISORDER FREQUENT HEADACHES OTHER PLEASE LIST: ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY): ASPIRIN CODEINE LACTOSE INTOLERANCE SLEEPING PILLS NONE ANESTHETIC LOCAL DAIRY METAL SENSITIVITY SULFA DRUGS BARBITURATES LATEX NITROUS OXIDE SEDATION PENICILLIN/OTHER ANTIBIOTICS OTHER PLEASE LIST: MEDICATION INFORMATION ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): NONE ANTIBIOTICS/SULFA DRUGS ANTIHISTAMINES/ALLERGY DAILY ASPIRIN BLOOD PRESSURE MEDICATIONS BLOOD THINNERS CANCER/CHEMO MEDICATIONS CORTISONE/STEROIDS HEART MEDICATION/DIGITALIS INSULIN NITROGLYCERIN ORAL CONTRACEPTIVES OSTEOPOROSIS MEDICATIONS OTHER DIABETIC MEDICATIONS RECREATIONAL DRUGS THYROID MEDICATIONS TRANQUILIZERS OTHER (PLEASE LIST BELOW) DRUG NAME DOSAGE REASON PRESCRIBED PATIENT REGISTRATION & HISTORY 3/6

Financial Guidelines We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines. Insurance We accept all major dental insurance payments, however we may not be an in network provider for your plan. If we are not an in network provider, review your plan details, as in many cases insurance reimbursement is very similar. Payments - We are only in network for Delta Dental Premier, United Health Care, and Assurant. initial - It is the patient s responsibility to know and understand their insurance coverage. Many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level. Please understand, that we do our best to keep our patients updated with their insurance coverage but NO ESTIMATE IS A GUARANTEE OF PAYMENT. Patients are responsible for all charges not paid by your insurance. Initial - Workers Compensation claims will be filed for you. Please understand the carrier will assign a dollar amount that will be paid towards the claim, which may or may not cover the entire fee. The patient is responsible for paying the treatment total on the day of service. Any insurance payments received would then be reimbursed back to the patient. - Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. - Patient portion or patient co-pay is due at the time services are rendered - unless prior financial arrangements have been made. - Payment Information: o All major credit cards are accepted (Visa, MasterCard, Discover) o 10% Discount for our uninsured cash/check/debit paying patients o Various financing options with CareCredit and CitiHealth - Balances left over 90 days may be turned over to our collection agency if alternative payment arrangements have not been made. Initial Short Cancelled/ Missed Appointments - Unless an emergency occurs, we expect to run on time for your appointments, and we appreciate the same courtesy from you. Please give 48 hours notice if you are unable to keep your reserved time. Any combination of two missed or short cancelled appointments in a 12 month period may result in dismissal from our practice. By signing below I acknowledge I have read and understand the guidelines above. Initial Signature Date: PATIENT REGISTRATION & HISTORY 4/6

ACKNOWLEDGEMENT OF PRIVACY PRACTICES Updated 2013 My signature confirms that I have been informed of my rights to privacy regarding my protected personal and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand the terms in which my personal health and identification information may be used. I have been informed of my dental provider s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office 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 and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Signature Printed Name Date RELATIONSHIP TO PATIENT: ADULT PATIENT PARENT GUARDIAN OTHER Please list any dependent children under the age of 18 also covered by this acknowledgement: I give permission for the following communications to be used by Dr. Kurt Kwiatkowski DDS, SC: Cell phone: Text Message reminders permitted Home phone Work E-Mail I am granting permission for Dr. Kurt Kwiatkowski DDS, SC to disclose their identity to anyone who may answer my home, work or cell phone. I am granting permission for Dr. Kurt Kwiatkowski DDS, SC to leave a message with any person who may answer my phone or on my voicemail of the following numbers: Home Phone Cell Phone Work Phone None- please just ask for a call back Other: I would like to give permission for the following person(s) to have access to personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above: FOR OFFICE USE ONLY: We were unable to obtain the patient s written acknowledgement of our Notice of Privacy Practices due to the following reason: The patient refused to sign Communication barriers Emergency situation Other please list: PATIENT REGISTRATION & HISTORY 5/6

PATIENT CONSENT- PAYMENT AUTHORIZATION SIGNATURE ON FILE To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my medication changes, I shall inform the dentist and staff at the next appointment without fail. I hereby authorize payment directly to Dr. Kwiatkowski of the dental benefits otherwise payable to me. I hereby authorize Dr. Kwiatkowski to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. By signing below, I acknowledge that I have read and understand the statements mentioned above. Signature: Date: Print Name: PATIENT REGISTRATION & HISTORY 6/6

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