Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n

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Shore Smiles Family & Cosmetic Dentistry 654 Newman Springs Road, Lincroft, New Jersey 07738 Phone: 732-747-4444 Fax: 732-747-4003 Welcome Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n Date Name Address Nickname Home Phone Cell Phone City State Zip E-Mail Sex M F Minor Single Married Long Term Partner Divorced Widowed Separated Soc. Sec. # Birthdate Age Employer Business Address Occupation Business Phone Who should we thank for referring you? In case of an emergency, contact? Phone Person Responsible For Account? P r i m a r y I n s u r a n c e Relationship To Patient Birthdate Soc. Sec. # Address Home Phone City State Zip Responsible Party Employed By Business Address Occupation Business Phone Insurance Company Insurance Company Address Subscriber I.D. Group # Be Sure To Print and Fill Out Page 2 Page 1 of 2

Former Dentist City, State Date Of Your Last Dental Visit Please check all that apply: Bad Breath... Bleeding Gums... Blisters on Lips or Mouth... Finger Nail Biting... Grinding Teeth... Lip or Cheek Biting... Physician s Name Loose Teeth or Broken Fillings... Orthodonic Treatment... Pain Around Ear... Periodontal Treatment... Sensitivity to Cold... Sensitivity to Hot... Date Of Last X-Rays How Often Do You Floss How Often Do You Brush Date Of Last Visit Sensitivity to Sweets... Sensitivity when Biting... Frequent Headaches... Jaw, Head, or Neck Injuries... Jaw Difficulty: Clicking and/or Pain... Tooth Pain... 1. Are you currently under medical treatment? Y N 6. Have you had allergic reaction 2. Are you currently taking any medication? Y N to the following: (Please List) 3. Do you smoke? (Cigarettes, Cigars, Chewing Tob.) How often? 4. Alcohol Use? Y N How Often? 5. Drug Use? Y N D e n t a l H i s t o r y M e d i c a l H i s t o r y 6. (Woman Only) Are You Pregnant? Y N Are You Nursing? Y N Are You Taking Birth Control Pills? Y N (Please Check All That Apply) AIDS... Anemia... Arthritis, Rheumatism... Artificial Heart Valves... Artifical Joints... Asthma... Back Problems... Bleeding abnormally, w/ extractions or surgery.. Blood Disease... Cancer... Chemical Dependency... Chronic Fatigue Syndrome... Circulatory Problems... Congenital Heart Lesions... Cortisone Treatments... Cough - persistent or bloody... Diabetes... Y N Emphysema... Epilepsy... Fainting or Dizziness... Glaucoma... Headaches... Heart Murmur... Heart Problems... Hepatitis -Type... Herpes... High Blood Pressure... HIV Positive... Jaundice... Jaw Pain... Kidney Disease... Latex Sensitivity... Liver Disease... Low Blood Pressure... Mitral Valve Prolapse... A s s i g n m e n t a n d R e l e a s e Local Anesthetics (eg. novacaine)... Penicillin or other Antibiotics... Sulfa Drugs... Barbiturates... Sedatives... Iodine... Aspirin... Other Nervous Problems... Pacemaker... Psychiatric Care... Radiation Treatment... Respiratory Disease... Rheumatic Fever... Scarlet Fever... Shortness of Breath... Sinus Trouble... Stroke... Swelling of Feet/Ankles... Swollen Neck - Glands... Thyroid Problems... Tonsillitis... Tuberculosis... Tumor or growth on head/neck... Ulcer... Veneral Disease... I hereby authorize payment directly to for all insurance benefits otherwise to me for services rendered. I understand that I am responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature of Responsible Party Date: Page 2 of 2

To My Valued Patient, I welcome you to our dental home. This year marks the beginning of many exciting changes in my office. I have made many efforts to improve service and quality of care for you. We are an extraordinary dental practice. We give exceptional service and the highest quality of care so that you regain and maintain your health as quickly, efficiently, and inexpensively as possible. I have a purpose: To maintain optimal oral health and to improve the way you feel about your smile. I also have a personal, professional, and ethical responsibility to care for your dental health to the best of my ability. In order to provide extraordinary care, we make the following commitments to you: 1. We will treat you like family and always consider your comfort and well being. 2. We are an ON TIME practice. We will see you on time and get you out on time unless there is an emergency. 3. Cleanliness and infection control are of the utmost importance. We have the latest sterilization technology and disinfect each treatment room after every patient. 4. When we make an appointment it is an agreement with you. The doctor, assistant, and/or hygienist devote time exclusively for you. Unlike other offices, we do not double book our patients because you deserve our undivided attention. 5. We are proud of the quality of our work and we guarantee it. 6. We will never perform dentistry unless we have your written consent saying that you understand the treatment and are aware of the fee and payment options. 7. It is our policy to ensure complete satisfaction of all of our patients with the service and care they receive at our office. 8. Insurance: Treatment recommendations are based on your health and not on your insurance or lack thereof. Remember insurance companies are not concerned about your health or well being - we are. 9. It is our goal to eliminate all potential dental emergencies you may have by providing care for you before it becomes a problem. In the rare instance that you do have an emergency we want you to be assured we will take care of you. 10. We will provide you with an ESTIMATE of insurance benefits. We are not responsible for what your insurance does not cover. In return for our commitments, we need to make the following agreements: 1. -Shows are not acceptable. If you cannot keep an appointment (except in the case of an emergency) you are expected to call within 48 business hours of your appointment to reschedule. t showing up for scheduled a appointment not only compromises your health, but inconveniences other patients who may have requested an office visit during your scheduled appointment. If you miss an appointment you must make it up. There is a $75.00 fee for all no-show, or cancelled appointments. All fees will be donated to Gilda s Club, a non-profit charity for cancer research and treatment. 2. We request that you be on time or early for your appointment. If you are more than 10 minutes late, you may have to reschedule your appointment. 3. In order to maintain the guarantee for your restorative work, you must keep your hygiene visit in the month that you are due. If you do not keep your hygiene visit on schedule, your guarantee is void. 4. We run a Zero Balance office. We expect payment in full prior to the time treatment is provided. 5. If you have insurance it is your responsibility to be aware of what your benefits are. Remember insurance companies are not concerned about your health or well being we are. You are fully responsible for any treatment performed. Your benefits are a contract between you and your insurance company. 6. If we are not meeting any of our commitments, we ask that you tell us. We will do everything in our power to make it right. 7. True emergencies are swelling, bleeding, severe pain that has kept you up at night or that requires medication. If you have any of these symptoms we ask that you call us right away. We will provide you with the next available emergency appointment. We do set aside time each day for emergencies. 8. We are confident you will appreciate our care and will want to tell your friends and family so they can receive the same quality service. Thank you for joining our family and we look forward to treating you for many years. David M. Herman, DMD, LLC & Shore Smiles Family Signature Date

Shore Smile Family & Cosmetic Dentistry ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * * Yo u M a y R e f u s e To S i g n T h i s A c k n o w l e d g e m e n t * * I,, have recieved a copy of this office s tice of Privacy Practices. (Please Print Name) (Signature) (Date) F o r O ffi c e U s e O n l y We attempted to obtain written acknowledgement of receipt of our tice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association All Right Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

The shor test distance between two people is a smile. Mark Twain S M I L E A N A LY S I S Q U E S T I O N A I R E Do you feel uncomfortable or self-conscious about your smile? Do you cover your mouth when you talk or smile? Are your teeth in alignment (straight)? Do you wish your teeth were whiter? Do you like the shape of your teeth? Are your teeth chipped? Can you see dark restorations in your teeth that bother you? Are there old crowns, bridges or fillings you don t like looking at in the mirror? What would you like your smile to look like?

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