TorranceOralSurgeryCenterBenjamin Yagoubian DDS, MD

Patient: (Mr., Mrs., Ms., Dr.) First Name _________________________ M.I. _______ Last Name: ______________________________ Sex: M F Driver’s Lic. # ______________________ Date of Birth ___________________ Social Security # ________________ Street ___________________________________ Apt # ________ City ___________________________ State _________ Zip _________ E-mail _________________________________ Home Tel. # (______) _________________ Mobile Tel. # (______) _________________ Dentist ____________________________ Physician _____________________________ Referred By _____________________________

NOTE: IF YOU ARE 18 YEARS OF AGE OR OLDER YOU ARE RESPONSIBLE FOR YOUR OWN ACCOUNT Patient: Who will be responsible for your account? Self Spouse Father Mother Other Name __________________________________ Social Security # ____________________ Home Tel. # (______) __________________ Street ___________________________________ Apt # ________ City ___________________________ State _________ Zip _________ Employer _________________________________________________________________ Telephone # (______) ___________________

Primary Dental Insurance Company Name __________________________________________ Address ________________________________________ Tel. # (_______) ___________________________ Does your plan cover: Dental Medical Both Group# _________________________________

Primary Insured Party Name _________________________________ DOB:_______________ Relation to insured: Self Spouse Father Mother Other Address ______________________________________________________ City ___________________________ State _________ Zip ____________ Tel. # (____) _________________ S.S. #______________________

Secondary Dental Insurance Company Name __________________________________________ Address ________________________________________ Tel. # (_______) ___________________________ Does your plan cover: Dental Medical Both Group# __________________________________

Secondary Insured Party Name _________________________________ DOB:_______________ Relation to insured: Self Spouse Father Mother Other Address ______________________________________________________ City ___________________________ State _________ Zip ____________ Tel. # (____) _________________ S.S. #____________________

Employer Name _____________________________________________________________________ Tel. # (______) ________________________ Street ___________________________________ Apt # ________ City ___________________________ State _________ Zip _________

HAVEYOUHADORDOYOUCURRENTLYHAVE

Yes No NOTES HAVEYOUHADORDOYOUCURRENTLYHAVE

Yes No NOTES

RheumaticFever? Stroke? DamagedHeartValves/MitralValveProlapse?

ThyroidTrouble?

HeartMurmur? Diabetes? HighBloodPressure? LowBloodSugar? LowBloodPressure? KidneyTrouble? Chestpain/Angina? AreYouOnDialysis? HearAttack? SwollenAnkles/arthritis/JointDisease? IrregularHeartBeat? StomachUlcers? CardiacPacemaker? ContagiousDisease? HeartSurgery? SexuallyTransmittedDisease? Bronchitis/ChronicCough? AreYouImmunosupressed? HayFever/SinusProblems? DelayInHealing? Tuberculosis? ATumororGrowth? Asthma? RadiationTreatment/Chemotherapy? Emphysema/DifficultyBreathing? HIV? OtherLungConditions? AreYouonaDiet? DoYouSmoke? AHistoryofDrugAbuse? BloodTransfusion? AHistoryofAlcoholAbuse? BloodDisorder(anemia)? Osteoporosis? BruiseEasily? EyeDisease/Glaucoma? Abnormal/ProlongedBleeding? MentalHealthProblems? Jaundice/Hepatitis/LiverDisease? ARemovableDentalAppliance? InfectiousMononucleosis? Pain&ClickingofJawswhenEating? GallbladderTrouble? MalignantHyperthermia? FaintingSpells? Haveyouhadanythingtoeatordrinkinthe

last8hours

Convulsions/Seizures/Epilepsy? Whoisdrivingyouhometoday?

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medications that you may be taking could have an interaction with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. Reason for today’s office visit: ______________________________________________________________________________________ Yes No Are you in good health? _____________________________ Height: _________________ Weight ________________ Have there been any changes in your general health in the past year? ___________________________________________ Are you under the care of a physician? ________________________________ Date of last visit: _____________________ If so, for what are you being treated? _____________________________________________________________________ Have you had any illness, operation or been hospitalized in the past five years? ___________________________________ Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? If so describe where _____________________________________________________________ Do you have a prosthetic joints? If so describe where _____________________________________________________________

CosmeticQuestionnaireHastherebeenaninteresttoenhanceyourfacialappearance?(YesorNo)________________________________________________________________Wouldyoulikeyourdoctortodiscuss/addressanyfacialfeatures?(YesorNo)___________________________________________________________Whichareaswouldyouhaveinterestindiscussing?(Forehead/Cheeks/Eyes/Nose/Lips/Neck)________________________________________

I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his or her staff, responsible for any errors or omissions that I have made in the completion of this form Signature of Patient: ________________________________________________________ Date: _________________ Signature of Nurse: _________________________________________________________ Date: _________________

MEDICATIONS ARE YOU NOW TAKING…. Yes No Notes ARE YOU NOW TAKING…. Yes No Notes Blood Thinners? Plavix, Coumadin? Fosamax, Actonel, Aredia, Denosumab? Tranquilizers? List all medications: Cortisone?

ALLERGIES ARE YOU ALLERGIC TO OR HAD A REACTION TO….

Yes No Notes ARE YOU ALLERGIC TO OR HAD A REACTION TO….

Yes No Notes

Local Anesthetics? Codeine or other narcotics? Penicillin? Other medications? Other Antibiotics? Allergies other than drug allergies (please list below)? Sodium pentothal, valium, or other tranquilizers?

Asprin? Latex? WOMEN

Yes No Notes Yes No Notes Is there a possibility of pregnancy? Are you nursing? Estimated deliver date? ______/______/______ Are you taking birth control pills?

Women Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

IS THERE ANY CONDITION CONCERNING YOUR HEALTH THAT THE DOCTOR SHOULD BE TOLD? Yes No

Benjamin Yagoubian DDS, MD 23451 Madison Street Suite 120 Torrance, CA 90505 (310)373-0667

Photo release form

I hereby grant Torrance Oral Surgery Center permission to use my likeness in a photograph(s) in any and all of its publications, including website entries, without payment or any consideration. I understand and agree that these materials will become the property of Torrance Oral Surgery Center. I hereby irrevocably authorize Torrance Oral Surgery Center to edit, alter, copy, exhibit, publish, or distribute this photo for purposes of publicizing Torrance Oral Surgery Center programs or for any other lawful purposes. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. I give my consent for the following types of photographs to be used:

o Before and after photos of teeth/gums/mouth only.

o Before and after photos of teeth/gums/mouth and face with my eyes backed out.

o Before and after photos of teeth/gums/mouth and face.

o Other: _______________________________________________________

Name: ______________________________________Date: ______ / _______ /_______

Signature: ___________________________________

Parent/guardian: ______________________________Date: ______ / _______ /_______

Signature: ____________________________________

Benjamin Yagoubian DDS, MD 23451 Madison Street Suite 120 Torrance CA 90505

(310) 373-0667

Cancellation and Broken Appointment Policy We understand that unforeseen events and circumstances may arise and that you may need to cancel or change your scheduled appointment. If this happens, we respectfully ask that requests to change scheduled appointments be made at least 48 hours, in advanced, on a business day.Cancellations must be made directly with our scheduling staff and should not be left after hours on the message machine. Our doctors want to be available for your needs and the needs of all our patients. Our priority is our patient’s dental health. When a patient does not show up for a scheduled appointment, another patient in need loses the opportunity to be seen. Any appointment cancellation given with less than a 48 hours notice or left on a voicemail less than 48 hours prior to a scheduled appointment will be marked as a broken appointment. If you don’t show up to your scheduled appointment and do not contact our office within the required time, this will be considered a missed appointment. A fee of $75.00 will be charged to you for a broken or missed appointment ; this fee cannot be billed to your insurance company and will be your direct responsibility. Our office makes every effort possible to help you keep your scheduled appointments with courtesy reminders such as text, email, and voice messages. Please let us know how you would like to be contacted in the future for appointment reminders:

o Email, Text, and Voice o Email and Text o Email and Voice o Text and Voice o Voice Only

My current e-mail address is: _________________________________________ My current cell phone number is: ( ____ ) ______ - _______ I have read and understand the office cancellation policy: Patient /Guardian Signature: ____________________________ Date: ____ / ____ / ____ Printed Name: _________________________________

Benjamin Yagoubian DDS, MD 23451 Madison Street Suite 120 Torrance, CA 90505

(310)373-0667

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FINANCIAL POLICY

Our primary goal is not to allow the cost of treatment to prevent you from benefiting from the quality care you need or desire. In our office, we strive to maximize your insurance benefits and make any remaining balance easily affordable. Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We charge what is the usual and customary fee for this area. We will assist you with your benefit eligibility before treatment to help you calculate your estimated costs and maximize your insurance. We will be sensitive to your financial circumstances and do everything possible to help you achieve oral health.

As a courtesy, we will assist with the processing of all insurance claims. We will provide an insurance estimate to you; however, it is not a guarantee that your insurance will pay exactly as estimated. We will strive to provide an accurate estimate; however, your insurance company and your plan benefits are ultimately determined by the carrier. All charges incurred are your responsibility, regardless of insurance coverage. As your dental care provider, our relationship is with you—our patient—not with your insurance company. Your insurance policy is a contract between you, your employer and your insurance company. Our office is not a party to that contract.

Please know that we will do everything possible to see that you receive the full benefits of your policy by filing your claim the day of your appointment, and following it for the next 60 days. Insurance payments are ordinarily received within 30-60 days from the time of filing. If payment is not received within 60 days of the filing date, and/or your claim is denied, you will be responsible for paying the amount in full immediately. Any amount not paid will be subject to 18% interest per annum. We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

We accept the following forms of payment: Cash, Visa, MasterCard, and Amex. In addition, we offer CareCredit and Lending Club as financing options, both offering a full range of No Interest and Extended Payment Plans for treatment fees from $1 and up. At this time, our office does not accept checks.

Payment for services is due at the time services are rendered.

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. Most often, financial misunderstandings can be managed with a phone call. Please feel free to contact our wonderful staff at any time to discuss any concerns you may have. Thank you for understanding our Financial Policy.

DEPOSIT POLICY

Due to the extensive amount of time our staff and doctors devote to preparing and reserving uninterrupted time, patients with extensive treatment and or implant surgery will be required to provide a deposit of 30% of the treatment fee to make your reservation. This deposit is non-refundable, as time and dental materials have been ordered for your specific treatment.

COLLECTIONS Any account that has not received payment in 60 days will be handed over to a collection agency that will pursue the responsible party for reimbursement. This will negatively impact your credit history and limit the treatment you can receive at our office.

Thank you, for understanding our financial policies. Please let us know if you have any questions or concerns. We look forward to providing the highest quality dental care in the most relaxing and caring atmosphere.

To pursue treatment, your initials and signature is required on this form as well as any other forms required by your insurance company.

Benjamin Yagoubian DDS, MD 23451 Madison Street Suite 120 Torrance, CA 90505

(310)373-0667

Page2of2Yourinitialshere____________

AGREEMENT: I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided by this office for my dependents or myself is my own, and/or attorney fees will be added to any overdue balance that requires collection initiatives. I understand that in the absence of prompt payment, my personal and financial records concerning these professional services will be released to Torrance Oral Surgery Center’s legal representative(s) for collection. The legal representative will act as the providers “business associate” in compliance with the federal Health Insurance Portability and Accountability Act. By signing below, I further consent to be contacted by the dentist, any agent of Torrance Oral Surgery Center, or any collection agency (or agent thereof) or attorney to whom an unpaid account balance has been assigned, or referred by mail at any address that I provide to the dental office and/or by fascismile, email or phone number (whether a cell phone or landline) that I provide to the dental office or any agent of Torrance Oral Surgery Center.

Signature of Patient or Responsible Party: ___________________________________ Date:__________