Placer Oral & Maxillofacial Surgery Nicholas Rotas, DDS, Inc.

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Placer Oral & Maxillofacial Surgery Nicholas Rotas, DDS, Inc. PLACER Oral & Maxillofacial Surgery Nicholas Rotas, DDS, Inc. Patient Information: 9241 Sierra College Blvd., Suite 150 Roseville, CA 95661 Tel: 916.773.1188 Fax: 916.773.1898 www.placeromfs.com Patient Name Last Name MI First Name Referred By Address Apt. # Home Phone ( ) Work Phone ( ) Cell Phone ( ) E-Mail Employer Occupation How Long Driver s License Number Expires Social Security Number Birthdate Age Sex: o Male o Female If Student, school attending o Full-Time o Part-Time If necessary, can you provide documentation of enrollment status? o Yes o No Spouse s Name Occupation How Long Employer Work Phone ( ) Social Security Number Birthdate Person Financially Responsible: Name Last Name MI First Name Address Apt. # Home Phone ( ) Work Phone ( ) Cell Phone ( ) E-Mail Employer Occupation How Long Driver s License Number Expires Social Security Number Birthdate Spouse s Name Occupation How Long Employer Work Phone ( ) List name of guardian with which the patient resides Insurance Information: Primary Dental Insurance Company Name Subscriber s Name Subscriber s of Birth Subscriber s Social Security Number Group ID # Employer Employer Phone ( ) Insurance Carrier Carrier Phone ( ) Teamster Name / Local Number Address to Mail Claims to

Secondary Dental Insurance Company Name Subscriber s Name Subscriber s of Birth Subscriber s Social Security Number Group ID # Employer Employer Phone ( ) Insurance Carrier Carrier Phone ( ) Teamster Name / Local Number Address to Mail Claims to Medical Insurance Company Name Subscriber s Name Subscriber s of Birth Subscriber s Social Security Number Group ID # Employer Employer Phone ( ) Insurance Carrier Carrier Phone ( ) Teamster Name / Local Number Address to Mail Claims to Statement of Financial Responsibility: I agree to be financially responsible for all services rendered by the treating dentist. A payment on account or an insurance co-payment may be due at the time services are rendered. I will be financially responsible for all charges not covered by my insurance company. I agree to pay all financial obligations in a timely fashion. I accept that all delinquent accounts will bear interest at the rate of 18% per annum (1.5% per month), but that special financial arrangements can be made in certain circumstances. I understand that a percentage of my surgery may be covered under my dental or medical insurance plan. I understand that all efforts will be made to determine benefits and co-payment information prior to my treatment. I understand that I will be responsible for all co-payments, deductibles, and non-covered procedures on or before the day of surgery. In the event that the insurance company denies a claim after a procedure has been completed, I understand that I am responsible for the balance on the account. We are happy to assist you in filing the necessary forms to help you receive the full benefit of your dental coverage. Insurance policies vary greatly; therefore please understand that we can only estimate your insurance coverage in good faith. The insurance relationship constitutes an agreement between the carrier, employer and the patient. As such, we can make no guarantee of the estimated coverage or insurance payment. Please know that we will do everything within reason to see that you receive the full benefits of your policy. Assignment of Insurance Benefits: I hereby authorize and request my insurance company to pay directly to the Doctor the amount due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense. I will be responsible for payment of the difference, and if the nature of the disability be such that it is not covered by the policy, I will be responsible to Placer Oral Maxillofacial Surgery for payment of the entire bill. Yearly Update: Health Address Telephone Insurance Health Address Telephone Insurance Health Address Telephone Insurance

Medical History: Patient Name Last Name MI First Name Height Weight In the following questions, check YES or NO, whichever applies to you. Your answers are for our records only and will be considered confidential. Thank you. Yes No 1. Has there been any change in your general health within the past year?... o o 2. When was your last physical exam? 3. Are you now under the care of a physician?... o o If yes, for what condition(s)? 4. Have you had a serious illness or operation(s)?... o o If so, what was the illness or operation? 5. Have you been hospitalized or had serious illness within the past five (5) years?... o o If so, what was the problem? 6. Do you have, or have you had, any of the following problems or diseases? a. Rheumatic fever or rheumatic heart disease... o o b. Congenital heart lesions or heart murmurs... o o c. Cardiovascular disease (chest pains, angina, heart attack, coronary insufficiency, coronary occlusion)... o o d. Stroke, hardening of the arteries, artiosclerosis... o o e. o High or o Low blood pressure... o o f. Bleeding problems or bruising easily... o o g. Asthma... o o If yes, have you required and emergency room visit for a shot or breathing treatment?... o o h. Shortness of breath... o o i. Tuberculosis or emphysema... o o j. Persistent cough, coughing up blood... o o k. Diabetes... o o l. Fainting spells, seizures, dizziness... o o m. Hepatitis, jaundice, or liver disease... o o n. Sinus problems... o o o. Hay fever... o o p. Headaches... o o q. High or low thyroid symptoms... o o r. HIV positive, AIDS, or ARC... o o s. Venereal disease (gonorrhea, syphilis)... o o t. Herpes / cold sores... o o u. Dry mouth, excessive thirst... o o v. Glaucoma, eye disease, blurred vision... o o w. Arthritis, rheumatism, joint pain, stiffness... o o x. Kidney / bladder disease, difficult or frequent urination, blood in urine... o o y. Stomach ulcers, problems... o o z. Tumors, cancer... o o aa. Anemia... o o bb. Sleep apnea... o o If yes, do you use CPAP?... o o dd. Emotional or psychiatric problems... o o 7. Do you have, or have you had, any of the following: a. Radiation treatments or chemotherapy... o o b. Artificial joint(s)... o o c. Prosthetic heart valve or pacemaker... o o

d. Blood transfusions or abnormal bleeding... o o If yes, please explain 8. Are you taking, or have you taken, the following in the last year? a. Antibiotics or Sulfa drugs... o o b. Anticoagulants or blood thinners (Coumadin / Plavix)... o o c. Aspirin... o o d. Digitalis... o o e. Nitroglycerin... o o f. Medicine for high blood pressure... o o g. Cortisone or steroids... o o h. Antihistamines... o o i. Insulin or diabetes medications... o o j. AZT or other Anti-Retroviral... o o k. Fosamax, Boniva, Zometa, Aredia or any other "Bisphosphonate" drug... o o If so, which drug Are you still taking this l. Tranquilizers... o o m. Diet pills... o o n. Natural supplements... o o o. Recreational drugs... o o p. List all medications you are currently taking q. Please list any medicine, drug, food, or material that you are allergic to (e.g. latex, Penicillin) 9. Do you have any disease, condition, or problem not listed above... o o 10. Have you, or any family member, had trouble with general anesthesia... o o 11. Do you smoke... o o If yes, how much per day, for how many years 12. Alcohol consumed: daily, weekly, monthly 13. Why have you come to see us today Women: 14. Are you pregnant... o o 15. Are you breast feeding an infant... o o 16. Are you taking oral contraceptives (birth control pills)... o o

Signatures: To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and / or medications. I consent to the taking of clinical photos in the course of diagnostic and surgical procedures for use of treatment, educational, or research purposes. I authorize the release of any medical or other information necessary to process insurance claims and I authorize payment of benefits to the treating physician / dentist for the services provided. I also request payment of government benefits (Medicare) to the treating physician / dentist. HIPAA Compliance Statement: (found under HIPPA/Privacy Policy) o I acknowledge that I have read a copy of the office s NOTICE OF PRIVACY PRACTICes and rights. I have read the notice and I understand my rights and the office s privacy policies. o Patient refuses to sign the notice. Employee name and date: Name o The patient is unable to sign the acknowledgement or is a minor. If the patient is a minor or represented by a personal representative, the authorized guardian / representative has signed below. Patient Signature

9241 Sierra College Blvd., Suite 150 Roseville, CA 95661 T: (916) 773-1188 F: (916) 773-1898 Consent for Shared Information with Family & Friends Under the HIPAA Privacy Law we are permitted and we may make a professional judgment that certain disclosures are in your best interests even without this signature. I understand that information is limited to verbal discussions and that no paper copies of my protected healthcare information will be provided without my signature on a Release of Information Form. The name(s) listed below are family members or friends to whom I grant permission for Placer Oral and Maxillofacial Surgery and representatives at our practice to verbally discuss my care using their best judgment and grant them permission to disclose dental information that is relevant to my care or relevant for payment. Name Relationship Phone Number 1 2 3 4 Regarding the following: Appointment Reminders/Changes Account Payments/Balances Cost Estimates Needed Treatment/Completed Treatment It will be my responsibility to keep this information up to date, as I recognize that relationships and friendships may change over time. This consent will be considered valid until such time that I revoke it in writing. I reserve the right to revoke it at any time. Printed Name (Patient/Parent) Signature (Patient/Parent) 2016 ACS Technologies, LLC Unauthorized Reproductions Prohibited Version 2 01/03/2016 Page 3 of 3

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