1

I Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you,

We look forward to working with you in maintaining your dental health.

Patient Information I Name Soc. Sec. #

Last Name First Name Initial 1 Address

L

>ity State Zip Home Phone

r Cell Phone Email

Sex 0 M 0 F Age Birthdate O Single O Married O Widowed O Separated 0 Divorced r Patient Employed by Occupation

hsiness Address Business Phone

I '

Business Email

Whom may we thank for referring you? L

Jotify in case of emergency Home Phone

1 Zell Phone Business Phone

Email 1 Primary lnsurance

Person Responsible for Account Last Name First Name Initial

I Relation to Patient Birthdate Soc. Sec. #

Address (if different from patient) Home Phone

State Zip

Cell Phone Email

Person Responsible Employed by I Occupation Business Address Business Phone

I Business Email

Insurance Company Phone

lnsurance Email

Contract # Group # Subscriber #

Name of other dependents under this plan

Additional l nsurance Is patient covered by additional insurance? O Yes O No

Subscriber Name Relation to Patient Birthdate

Address (if different from patient) Soc. Sec. #

State Zip Home Phone 1 Ez Phone Email Subscriber Employed by Business Phone

L Business Email

Insurance Company Phone

lnsurance Email

Contract # Group # Subscriber #

Name of other dependents under this plan

Please complete both sides.

I C

Dental History What would you like us to do today? Are you in dental discomfort today?

Former Dentist Address

Dentist's Email Phone L

Date of last dental care Date of last x-rays

r Check ( J ) yes or no if you have had problems with any of the following:

0 Y 0 N Bad breath OY 0 N Food collection between teeth 0 Y 0 N Periodontal treatment 0 Y 0 N Sensitivity to sweets 0 Y 0 N Bleeding gums 0 Y O N Grinding or clenching teeth 0 Y O N Sensitivity to cold 0 Y O N Sensitivity when biting

, 0 Y 0 N Clicking or popping jaw 0 Y O N Loose teeth or broken fillings 0 Y O N Sensitivity to hot U Y 0 N Sores or growths in mouth r

How often do you brush? Floss?

, How do you feel about the appearance of your teeth? I ) Have YOU ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? O Y Q N ' Other information about your dental health or previous treatment A

Medical History 1 Physician's name Phone

Date of last visit Have you had any serious illnesses or operations? O Y 0 N A If yes, describe

Are you currently under physician care? O Y O N If yes, describe

Have you ever had a blood transfusion? O Y O N If yes, give approximate dates

Have you ever taken Fen-PhenIRedux? O Y O N . . - - - - -

I Women: Are you pregnant? O Y O N Nursing? 0 Y 0 N Taking birth control pills? O Y O N .-#. - Check ( J ) yes or no whether you have had any of the following:

2 Y 0 N AIDSIHIV Positive 2 Y O N Anaphylaxis

r QY O N Anemia 0 Y 0 N Arthritis, Rheumatism

I 0 Y O N Artificial heart valves 0 Y O N Artificial joints '

0 Y 0 N Asthma - J

O Y 0 N Atopic (allergy prone)

I 0 Y 0 N Back problems hr 0 Y 0 N Blood disease ' ' 0 Y 0 N Cancer 0 Y 0 N Chemical dependency O Y O N Chemotherapy O Y 0 N Circulatory problems O Y 0 N Cortisone treatments

OY 0 N Cough, persistent 0 Y 0 N Cough up blood 0 Y 0 N Diabetes 0 Y O N Epilepsy 0 Y O N Fainting O Y 0 N Food allergies O Y 0 N Glaucoma O Y O N Headaches O Y 0 N Heart murmur OY 0 N Heart problems Describe 0 Y 0 N Hemophilia1

Abnormal bleeding 0 Y 0 N Herpes 0 Y 0 N Hepatitis 0 Y O N High blood pressure

0 Y O N Jaw pain 0 Y 0 N Kidney disease or

malfunction 0 Y O N Liver disease 0 Y 0 N Material allergies

(latex, wool, metal, chemicals)

OY 0 N Mitral valve prolapse 0 Y 0 N Nervous problems O Y 0 N Pacemaker1

Heart surgery O Y 0 N Psychiatric care O Y O N Rapid weigM gain or loss 0 Y 0 N Radiation treatment O Y O N Respiratory disease 0 Y 0 N RheumatidScarlet fever

0 Y 0 N Shingles 0 Y 0 N Shortness of breath OY 0 N Skin rash O Y 0 N Spina Bifida 0 Y 0 N Stroke O Y 0 N Surgical implant 0 Y 0 N Swelling of feet

or ankles 0 Y O N Thyroid disease or

malfunction 0 Y 0 N Tobacco habit 0 Y O N Tonsillitis

-1 0 Y 0 N Tuberculosis 0 Y O N UlcerlColitis - O Y 0 N Venereal disease

IS patient currently taking any medications? If yes, list all: - Does patient have drug allergies? If yes, list all:

Authorization I I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information

will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

L I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otheyise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

, &; - #

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand ihat I am financially responsible for all charges whether or not paid by insurance. - -

. . Signature Date

Payment Is due in full at tlme of treatment, unless prior arrangements have been approved. R1

HIPAA COMPLIANCE INFORMATION

1. Release of Private Informatioil to a Patient's Spouse:

It is understood that our office cannot discuss your healthcare with his or her spouse. If a spouse is going to make healthcare decisions for a patient that becomes unable to do so, the patient must have a duly executed healthcare proxy.

2. Release of Private Information for Coordination of Benefits

If you are covered by more than one insurance plan we cannot share private information between policies or carriers for anyone other than the patient being referenced.

3. Release of Records Upon'Patient's Request

We will release your records or information upon request after you have signed the release form below.

I give permission to release any medical information deemed necessary for my treatment.

Signed: Date:

Leonard G. Episcopio, DDS 31 Oakland A\ienue M1amick, NY 10990

Phone: (845) 986-2929 Fax: (845)-986-7973

Payment is expected in full at time of service, unless you provide proof of dental insurance coverage. We accept Cash, Check, Mastercard, Visa, Discover and American Express.

Although we do not offer payment plans, we will be glad to assist you in applying for Carecredit, a service offered by GE Capital Consumer Card Co., for any major treatment plans over $300.00.

Please be advised that dental insurance is a contract strictly between you and your insurance company. We are happy to extend the courtesy of submitting your claims for you, however, it is your responsibility to know the extent and limits of your coverage and to provide us with accurate insurance information to process your claim efficiently. If we do not receive payment from your insurance company within 45 days after the submission of a claim, you will be expected to pay for all dental services. I11 the event of duplicate payment, you will be reimbursed. If you do not provide the necessary insurance information at the time of your appointment, we expect payment in full at time of service. We do not let the conditions of your insurance coverage dictate your dental health care we provide.

Any balance on your account is your responsibility whether the insuralce company pays or not. Secoild of subsequeilt billings will be subject to a $10.00 re-billing fee, unless other arrailgeinents have been made in advance.

We do reserve the right to charge for cancelled or broken appoiiltilleilts without a 48 hour advance notice.

I have read and accept the above Financial Policy.

Signature Date