Patient’s Name ___________________________________ Date of Birth ____________________

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

Patient’s Signature _________________________________ Date ___________________

Dentist’s Signature _________________________________ Date ___________________

Purpose of initial visit:

When was your last dental visit? What for?

Previous dentist’s name:

When was the last time your teeth were cleaned?

How often do you see a dentist?

Were dental x-rays taken?

Have you lost any teeth or have any teeth been removed? Yes or No

Have they been replaced? How?

Yes or No

Have you ever had any problems or complications with previous dental treatment? Yes or No

Do you clench or grind your teeth? Yes or No

Does your jaw click or pop? Yes or No

Have you experienced any pain or soreness in the muscles, your face or around your ear? Yes or No

Do you have frequent headaches, neck aches, or shoulder aches? Yes or No

Are any of your teeth sensitive to hot, cold, pressure, or sweets? Yes or No

Do your gums bleed or hurt? Yes or No

Have you experienced dry mouth? Yes or No

How often do you brush your teeth?

Do you use dental floss? How often?

Yes or No

Are any of your teeth loose, tipped, shifted, or chipped? What?

Yes or No

Do you feel that your breath is offensive at times? Yes or No

Are you unhappy with the appearance of your teeth? Yes or No

How do you feel about your teeth in general?

Have you ever had gum treatment or surgery? What? Where? When? Yes or No

Have you had any orthodontic work? Yes or No

DENTAL HISTORY

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

Patient’s Signature _________________________________ Date ___________________

Dentist’s Signature _________________________________ Date ___________________

General Physician’s Name:

When was your last complete physical exam?

Are you taking any medications or substances? (Please list below) Yes or No

Do you routinely take health related substances (vitamins, supplements)? Yes or No

Are you allergic to any medications or substances? Yes or No

Do you have any other allergies or hives? Yes or No

Are you sensitive to any metals or latex? Yes or No

(Women)Are you pregnant or suspect you may be? Yes or No

Have you ever been treated for or been told you might have heart disease? Yes or No

Do you have a pacemaker, artificial heart valve implant, or been diagnosed with mitral valve prolapse? Yes or No

Have you ever had rheumatic fever? Yes or No

Are you aware of any heart murmurs? Yes or No

Do you have high or low blood pressure? Yes or No

Have you ever had a serious illness or major surgery? What kind?

Yes or No

Have you ever had radiation treatment or chemotherapy treatment? Yes or No

Do you have inflammatory diseases such as arthritis or rheumatism? Yes or No

Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?

Yes or No

Do you have artificial joints/prosthesis? Yes or No

Do you have any blood disorders, such as anemia, leukemia, etc.? Yes or No

Have you ever bled excessively after being cut or injured? Yes or No

Do you have any stomach problems? Yes or No

Do have any kidney problems? Yes or No

Do you have any liver problems? Yes or No

Are you diabetic? Yes or No

Do you have fainting or dizzy spells? Yes or No

Do you have asthma? Yes or No

Do you have epilepsy or seizure disorders? Yes or No

Have you tested positive for any STDs, HIV, or AIDS? Yes or No

Have you had or do you test positive for hepatitis? Yes or No

Do you or have you had Tuberculosis? Yes or No

Do you smoke, chew, use snuff, or any other forms of tobacco? Yes or No

Do you regularly consume more than one or two alcoholic beverages a day? Yes or No

Do you habitually use controlled substances? Yes or No

Have you had psychiatric treatment? Yes or No

Do you have any other disease, problem, or condition not listed? (Please mention below)

Yes or No

Would you like to speak to the doctor privately about any problem? Yes or No

Do you have or think you have sleep apnea? Yes or No

MEDICAL HISTORY

Patient Name: __________________________________ Date of Birth: ___________________

Financial Policy and Photo/Testimonial Consent

Thank you for choosing us as your dental care provider. Our office is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment. All patients must complete our Information and Insurance form before seeing the doctor. Regarding Payment We accept the following forms of payment: Cash, Check, All major Credit Cards and Care Credit. Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the billing receptionist. If dentures, partial dentures, crown and bridge are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is cemented or inserted. The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist. Checks that are returned to our office from your financial institution are subject to a $40.00 returned check fee. This fee covers the processing fees that are charged to our office. Regarding Insurance Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event we do accept assignment of benefits and your insurance company has not paid your account in full within 60 days, the balance may be transferred to your account. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and customary under the terms of your insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is the usual and customary for our area. You are responsible for payment regardless of any insurance company arbitrary determination of usual and customary rates. Your complete insurance information must be presented at the time services are provided. Insurance claims cannot be backdated. Most benefits will be verified before your insurance company can be billed. All insurance co-pays and deductibles must be paid at the time of service. We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Broken Appointments We reserve the right to charge $75 for appointments cancelled or broken without a 24 hour notice We reserve the right to charge $150 for longer (bridges,crowns,etc.) appointments cancelled or broken without a 24 hour notice Photo Consent I grant permission to Dr. Samant to use my photograph and any testimonial I give regarding the dental care I receive. I have read these policies. I understand and agree to this policy. Signature of Patient or Responsible Party: ________________________________ Date:______________

REGISTRATION

PATIENT’S OR GUARDIAN’S SIGNATURE DATE

_________________________________________________________________ ______________________________________

Patient’s FULL Name ______________________________________ D.O.B_____________ Male Female How do you wish to be addressed: _________________________________

Single Married Separated Divorced Widowed Minor

Mailing Address______________________________________ City _________________ State______ Zip____________

Telephone: Home___________________________ Cell__________________________ Work______________________

Fax number________________________________ Email ___________________________________________________

Driver’s License Number __________________________ SSN#_______________________________________________

Employer______________________________________ Position _____________________ Employed since__________

Spouse/Parent Name____________________________ Spouse/Parent SSN#___________________________________

Spouse/Parent Employer _____________________________________________________________________________

Emergency Contact_________________________________________ Number _________________________________

Method of Payment: Insurance Cash Credit Card

Purpose of Visit_____________________________________________________________________________________

Whom may we thank for this referral ___________________________________________________________________

Dental Insurance

Employee Name________________________________

D.O.B ________________________________________

Employer Name________________________________

Insurance Co.__________________________________

Subscriber I.D _________________________________

SSN#_________________________________________

Consent

I consent to the diagnostic procedures and treatment by the dentist

necessary for proper dental care. I consent to the dentist’s use and

disclosure of my records (or my child’s records) to carry out treatment, to

obtain payment, and for those activities and health care operations that

are related to treatment or payment. I consent to the disclosure of my

records (or my child’s records) to the following persons who are involved in

my care (or my child’s care) or payment for that care. My consent to

disclosure of records shall be effective until I revoke it in writing. I

authorize payment directly to the dentist or dental group of insurance

benefits otherwise payable to me.

I understand that my dental care insurance carrier or payor of my dental

benefits may pay less than the actual bill for services, and that I am

financially responsible for payment in full of all accounts. By signing this

statement, I revoke all previous agreements to the contrary and agree to be

responsible for payment of services not paid, by my dental care payor.

I attest to the accuracy of the information on this page.

Consenf forUse and Disc/osure of Health lnfarmation u Release FarmAcknowleidgemenf of Rece ipt of JVoffce af Privary Pracfices

Patient / Guardian Giving Consent

Name

ffi"e W_"ht %"r*aem'"'*l''t'*f

Nd "

H. I. P. A, A,We,,a{*'d

Address

City State

Home Phone Wo* Phone L**J

Our practice has implsmented a program of Heafth Information Privacy Policies end Procodurss to prolect the intorest ofyou, our valued patienis. These are based on the requirements of the Health Insurance Portability snd ,{ccountability Act,H.l.p.A.A., under the Department of Health and Human Service$.

As of April 14, 2003 all Healthcare Providers are required to post this notice and to make a good faith effort to obtainsigned Consent from their patient$. This Consent fonn is legally necessar) for us to assist you with, but not limited to,tasks such as lnsurance pre-approval and filing, medical consultations if necessary, laboratory coodination and evenappointment reminders.

have read, reviewed and cansidered the contents of lhis Consent formand was given a copy of and have read your Notice of Privacy Practices. I understand, that by signing this Consent fonn,I am giving my consent to your disclosure and use of mine or my dependants (Minor Child, Foster Child or dher personwhom I am the legal guardian of) proteded health information in any form deemed necessary in conjunction with commonprac{ices and professional judgement.

$ignature Date

lf lhis Consenl is signed by a perconal representative on behalf of the palient, please complete the following:

Signature of Personal Representative Date

Fleas* Print Name of Perssnal Representative

Your Rightto Revoke Consent

You have the right to revoke this Consent by Eiving us wriften notice of your revocation. We retain lhe right to decline totreat you orto conlinue treatment should you choose not lo sign this Gonsent or choose to revoke it at a latertime.

You are entitled to a copy of this Consent after it is signed. We support your right to ths privacy of your healthinfofrngtisn. lf ytu'have any further questions about cur l*lealth Infonnalion Frivacy Policies and Procedures, pleaseinquire al the reception desk.

I ngOUfSf OF EXEMPTION S Please write your request for exemption on the back of this form.

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Snrrnxt Dutta0 GmupO lrw ffittqlo+.@4 2009-2003