Whom should we contact? _

Relation: _

Home Phone #: ( ) _

Work Phone #: ( ) _

Cell Phone #: ( ) _

Who is your Medical Doctor? _

Medical Doctor's Phone #: (

What You Prefer To Be Called: 0 Male0 Female

Birthdate: I I Age: SS#: _

Mailing Address: _

CITY

Home Phone #: ( ) _

Work Phone #: ( ) _

Cell Phone #: ( ) _

E-mail Address: _

Referred By: _

Employer: How Long? _

Employer's Address: _

STATE ZIP

Ext: _

CITY STATE ZIP

Occupation: _

Status: 0 Minor0 Single0 Married0 Divorced0 Separated0 WidowedSpouse's Name: _

Do you have children? 0 Yes 0 No How many? _

Name: _

Relation: _

Billing Address: _

CITY STATE ZIP

SS #: _

Drivers License #: _

Work Phone #: ( ) _Payment method: 0 Cash 0 Check

o CreditCard- Entercard# above(ifaccepted)

I hereby authorize assignment of my insuranceInitials rights and benefits directly to the provider for

services rendered. I fully understand I am solely responsi-ble for any balance not paid by my insurance company(if offered at this office).

Primary Dental InsuranceCo. Name: _

Address: _

CITY STATE ZIP

Phone #: ( _

Insured's ID#: _

STATE

Group # (Plan,Local,or Policy#)~. _

Insured's Name: _

Relation: Date of Birth: _--L._~_

Insured's Employer: _

Secondary Dental Insurance

Co. Name: _

Address: _

CITY

Phone #: ( _

Insured's ID#: _

Group # (Plan,Local,or Policy#): _

Insured's Name: _

______ Date of Birth: _~_-'-_

Insured's Employer: _

/ /

Reason for today's visit: 0 Exam 0 Emergency 0 ConsultationAre you in pain? 0 No 0 Yes How Long? _Please indicate il!I any of the following problems:o Discomfort, clicking or popping in jaw. 0 Lost/Broken Filling(s) 0 Stained teetho Red, swollen or bleeding gums. 0 Teeth grinding 0 Locking Jawo Sensitive tooth, teeth or gums. 0 Ringing in Ears 0 Bad breatho Blisters/Sores in or around the mouth. 0 Broken/Chipped tooth

o Other: ~Do you require pre-medication? 0 Yes 0 No 0 Don't know

Previous Dentist: ( __ )__ ---.~,..,....-Name Phone#

Last Dental exam: __ -.L-._----' _/ Last Dental X-rays:_~--,-~~-"---_~ /

Times a day you brush? Times a week you floss? _What type of tooth brush bristles do you use? 0 Soft 0 Medium 0 Hard

How would you rate your smile? (Worst) 1 2 3 4 5 6 7 8 9 1 0 (Best)

UPDATE(OFFICE USE)

MEDICAL HISTORYWhat medications are you taking? 0 Nerve pills 0 Pain killers (includingaspirin) 0 Muscle relaxerso Stimulants 0 Blood Thinners 0 Tranquilizers 0 Insulin 0 Meds for Osteoporosiso Other(s), please list: _

Have you ever taken: Bisphosphonates (ex.AredialFosamax)0 Yes 0 No Phen-fen/Redux 0 Yes 0 NoDo you have or have you had any of the following diseases, medical conditions or procedures?Y N HeartAttack / Stroke Y N Thyroid Problems Y N CancerlTumors Y NCosmeticSurgeryY N HeartSurg./Pacemaker Y N KidneyProblems Y N Shingles Y NXray or CobaltTreatmentY N Heart Murmur Y N Liver Problems Y N Hepatitis Y NChemotherapyY N RheumaticFever Y N RespiratoryProblems Y N HIV+/AIDS/ARC Y NAsthmaY N MitralValve Prolapse Y N Sinus Problems Y NArthritis/ Rheumatism Y N DifficultyBreathingY NArtificialValves Y N StomachProblems/Ulcers Y NArtificial Bones/Joints Y N Diabetes/HypoglycemiaY N Heart Disease Y N PsychiatricProblems Y N Emphysema Y N LeukemiaY N CongenitalHeart Defect Y NVenerealDisease Y N Fainting/Seizures/Epilepsy Y N AnemiaY N Chest Pains Y N Alcohol/DrugAbuse Y N Severe/FrequentHeadaches Y N High/LowBlood PressureY N Scarlet Fever Y N TuberculosisTB Y N FrequentNeck Pain Y N BleedingProblemsY N Nervousness Y N Jaw ProblemsTMJITMD Y N Back Problems Y NGlaucomaPlease list any other surgeries or medical conditions you have or ever had: _

Are you allergic to any of the following? 0 Latex 0 Penicillin / Amoxicillin 0 Tetracycline 0 Aspirin

o Dental Anesthetics 0 Foods: 0 Others: _

Do you use tobacco? 0 No 0 Yes/How used? How much? How long?__ ~

Please rate your general health from 1-10: Do you wear contact lenses? 0 Yes 0 NoFor women: Are you taking Birth Control pills? 0 Yes 0 No How many children have you had?_~_Are you Pregnant? 0 No 0 Yes/How long? Are you nursing? 0 Yes 0 No

• We invite you to discuss with us any questions regarding our services. The best Dental health services are basedon a friendly, mutual understanding between provider and patient.

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements havebeen made with the business manager. If account is not paid within 90 days of the date of service and nofinancial arrangements have been made, you will be responsible for legal fees, collection agency fees, interestcharges and any other expenses incurred in collecting your account.

• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I alsoauthorize the provider to release any information required to process insurance claims.

• I understand the above information and guarantee this form was completed correctly to the best of my knowledgeand understand it is my responsibility to inform this office of any changes to the information I have provided.

I acknowledge that I have received a copy of the Summary of Privacy Notice.

Initials Date

Date

Comments

Comments

Initials Date

Initials Signature =-c-~,......,--c-----=-c=---c--=--c----=-,......,--- Date__ '-------' _o Adult Patient/ /

Commentso Parent or Guardian o Spouse

First ImpressionForms, Inc. 1-800-99FORMSFORM# 3DGA1copyright©2011

Drum Point Family & Implant Dentistry PCGabriel Ruiz, D.M.D. & Associates

To My Valued Patient,

The goal of our dental team is to obtain optimal dental health for you and your family. We feel apersonal, professional and ethical responsibility to care for your oral health. With that said thescope of your oral health lies on your compliance with treatment, good quality home care andmaintaining a proper oral health maintenance program with our office and/or recommendedspecialists. Missed appointments and failure to comply with our recommended treatmentschedules and lor procedures prevent us from achieving our goal for your optimum dental health.If you cannot keep your appointments and do not adhere to our treatment recommendations, wewill not be able to continue treating you in good conscience. Therefore the following must beagreed upon:

• Broken appointments. Our office is committed to accommodating your schedulingneeds. In return, we expect 24 hours notice prior to rescheduling or canceling anappointment. This will allow us the opportunity to offer that appointment to anotherpatient and we can reschedule your appointment. There is a $50 fee for all brokenappointments and this fee is not covered by insurance.

• Timeliness is required. We will do our best to see you on time and get you out on timeunless there is an emergency. We request that you be on time for your visits.

• Cleanliness and infection control are of the utmost importance. We have the lateststerilization technology and disinfect each treatment room after each patient. We requestthat you brush your teeth prior to your given appointment.

• If you miss an appointment you must make it up. It is critical to your health to do so toavoid setbacks in the care and maintenance of your teeth and gums.

• Insurance: Treatment recommendations are based on your health not on yourinsurance or lack thereof. You agree to be financially responsible for either the fullamount of treatment, or the balance after payment by your dental insurance companyshould the claim be denied or be processed at a lesser benefit level. Your benefits are acontract between you and your insurance company.

• We run a Zero Balance office. We expect your deductible and/or co payment to be paidin full at the time treatment is provided. We have several financial options available forall of our patients. Please speak to our front office team if you have any questions.

• Our policy is to make your experience in our office an exceptional one. When wesucceed, we would appreciate you telling your family and friends about our office.

Gabriel Ruiz, D.M.D.

• Concerns. It is our policy to ensure the complete satisfaction of all of our patients withthe service and care they receive at our office. If there is a misunderstanding ormiscommunication between you and our office, we will do everything in our power tomake things right. This matter should be brought to our attention in an appropriatecordial manner at a time that we can give it the proper attention it deserves for aneffective resolution. You can expect that my team will treat you with the sameprofessional demeanor and efficiency as you would expect from them. We will actimmediately to resolve any upset that you may have with our office or one of our teammembers.

• Emergencies. It is our goal to eliminate all of the potential dental emergencies you mayhave by providing care for you before it becomes a problem. In the rare instance thatyou do have an emergency, we want you to be assured that we will take care of you. Inorder to do this we would like to define what a true emergency is. Swelling, bleeding,severe pain that has kept you up at night or require medication, or a restoration in avisible area that falls out are all considered emergencies. If you have any of thesesymptoms, we ask that you call us right away. We will provide you with the nextavailable emergency appointment. We do set aside time each day for emergencies.

We greatly appreciate your cooperation.

Patient Signature Date Office

131 Drum Point Rd., Brick, NJ 08723 Telephone 732.451.0400 Fax 732.451.0500

Signature of Patient, Parent, Guardian, or Personal Representative Date

Drum Point Family and Implant Dentistry

Financiali\greenment

I acknowledge that payment is due at the time of treatment, unless other arrangements aremade. I agree that parents, guardians or personal representatives are responsible for allfees and services rendered for treatment of a minor/child. I accept full financialresponsibility for aU charges for services or items provided to me, to my minor/child, orto the patient for whom Ihave legal responsibility. Iunderstand that filing a claim withmy insurance company does not relieve me from my responsibility for the payment of allcharges.

Relationship to PatientPlease print name of Patient, Parent, Guardian, or Personal Representative

Insurance i\ssignnment and Release

I certify that I, and/or my dependent(s), have insurance coverage with~-:-- -::---::-:- .: and assign-directly to Dr. _all insurance benefits, if any, otherwise payable to me for services rendered. I understandthat I am financially responsible for all charges whether or not paid by insurance. Iauthorize the use of my signature on aU insurance submissions.

The above-named doctor may use my health care information and may disclose suchinformation to the above-named Insurance Company (ies) and their agents for thepurpose of obtaining payment for services and determining insurance benefits payable forrelated services. This consent will end when my current treatment plan is completed orone year from the date signed below.

Signature of Patient, Parent, Guardian, or Personal Representative Date

Please print name of Patient, Parent, Guardian, or Personal Representative Relationship to Patient

Drum Point Family and Implant Dentistry131 Drum Point Rd

Brick, NJ 08723

ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

***You May Refuse to Sign This Acknowledgement***

I, , have received a copy of this office'sNotice of Privacy Practices.

Please Print Name Date

Signature

Other family members, or significant others that we can release information to.

Office Use

The Patient refused to sign our Notice of Privacy Practices Because: