Office Hours: Monday - Thursday 8:00 A.M. 5:00 P.M. New Patient Exams & Cleanings:

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1 We want to provide you with the best dental care possible in an efficient and timely manner. Please take a moment to review our office policies to help us achieve our goals in serving you. If you are a new patient, please download and complete all forms and bring them with you to your first appointment we look forward to meeting you! Office Hours: Monday - Thursday 8:00 A.M. 5:00 P.M. New Patient Exams & Cleanings: New patients will receive a comprehensive exam including charting, appropriate dental x-rays, patient education, and an examination by the dentist. We typically try to complete your cleaning the same visit but sometimes you might need to schedule an additional appointment to complete your cleaning. We know your time is valuable so we hope you understand the extra time is necessary to give your oral health the detailed attention it deserves. Appointment Cancellations: We know life can be hectic, so please let us know as soon as possible if you are unable to keep your appointment. Appointments that are cancelled with less than 24 hour notice will be considered broken. Because we reserved that time specifically for you, it becomes difficult for us to offer that reserved time to another patient who also needs dental care. We hope you understand how broken appointments negatively affect our schedule and impact other patients; therefore, we do reserve the right to charge a fee of $35 for the broken appointment. If we are running late, we will try to notify you as soon as possible. If we are unable to fulfill your appointment because a staff member or the dentist is absent due to illness, emergency, or if we have caused a scheduling error, we will reschedule you as soon as possible and apply a $35 credit to your account for any inconvenience we might have caused. Emergency Service: We provide on-call after-hours emergency service for our patients. I have read the above policies and fully understand their content and my responsibilities. Signed: Date:

2 Full Name: Today s Date: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: Male Female Marital Status: Married Single Divorced Widowed Birth Date: Age: SS: I would like to receive correspondences via If Student, Name of School/College: Employment Status: Full Time Part Time Retired t Employed Employer/Employer Address: Emergency Contact: Relationship: Phone: How did you hear about our practice? Responsible Party Responsible Party (if other than patient): Relationship: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Insurance Information Name of Insured: Relationship: Birth Date of Insured: Age: SS: Employer/Employer Address: Insurance Company: Insurance Company Address:

3 We consider our relationship with you to be of primary importance and will always recommend treatments based on your particular oral health needs, regardless of your insurance coverage or financial arrangements. For your convenience, we offer a wide range of financial options and welcome your suggestions and questions. A) 50/50 Payment (for treatment over $1,000) Half of the total payment is due when appointment is reserved, and the second half is due at the completion of the treatment. B) Payment Plans Pay for treatment over 6 to 12 months with no interest or low fixed rates. Please call our office for details. C) Prepayment in Full (for treatment over $1,000) A prepayment courtesy discount of 5% will be given for direct payment in full by cash, check, or credit card two business days before the first treatment visit. D) Senior Citizen Discount A courtesy discount of 10% will be given to our patients 65 or older if paying by cash or check and a courtesy discount of 5% if paying by credit card. E) Dental Health Plan Our low-cost, in-house dental plan. Please see our website or call us for details. Our office is insurance-friendly, so we are more than happy to file your insurance as a courtesy to you. Please understand that dental insurance is not designed to pay for all of your dental care; dental insurance usually has yearly limits. It is very important to remember that the dental insurance contract is between you and the insurance company. Ultimately, you are responsible for the cost of the treatment if your insurance does not cover any or all of the treatment. Payment is expected at the time of service and if you have insurance, we will expect your co-payment and deductible as well. For your convenience, we accept cash, check, Visa, MasterCard, American Express, Discover, and Care Credit. Please note that there is a $25 fee for all returned checks. If you ever have any questions about services, billing, or insurance, please ask any member of our staff to assist you or call our office at I have read the above policies and fully understand their content and my responsibilities. Signed: Date:

4 Your comfort is our priority. Please select from the following options: We can provide you with oral sedation to ease your mind. Would you like to discuss the use of a prescribed oral sedative to help ease your mind? (You must have someone drive you to and from your appointment) Blankets help keep you warm and relaxed. Would you like a blanket? Pillows can provide comfort for a sore neck or back. Would you like a pillow? We provide headphones for your listening pleasure. Would you like headphones? Is there anything else we can do to make your visit comfortable? Please place a check mark next to the statements that concern you or describe your problem. I gag easily. I feel out of control when I m lying down in the dental chair. I have not been to the dentist for a long time, and I feel uncomfortable about what you will say about my teeth and my dental hygiene. Pain relief is my top priority. I don t like shots. Please tell me all I need to know about my mouth. I like to have as much information as possible. My teeth are very sensitive. I don t like cotton in my mouth. I hate the noise of the drill. Please respect my time. I don t want to be left sitting in the reception area. I want to know the cost up front. money surprises please. I have difficulty listening and remembering what I hear while sitting in the dental chair. I have health problems and questions that we need to discuss.

5 MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel 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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? If yes, please explain: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Other If yes, please explain: Metal Latex Sulfa drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes, please explain: Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

6 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this tice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this tice while it is in effect. This tice takes effect (10/26/2011), and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this tice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our tice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this tice and make the new tice available upon request. You may request a copy of our tice at any time. For more information about our privacy practices, or for additional copies of this tice, please contact us using the information listed at the end of this tice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this tice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this tice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, or letters).

7 PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this tice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this tice. If you request copies, we will charge you $0.50 for each page, $20 per hour for staff time (amount to be decided) to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this tice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic tice: If you receive this tice on our Web site or by electronic mail ( ), you are entitled to receive this tice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this tice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: Telephone: Address: Fax: 2002, 2009 American Dental Association. All Rights 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. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002; April 30, 2009).

8 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ** You may refuse to Sign this Acknowledgement** I,, have received a copy of this office s tice of Privacy Practices. (Please Print Name) (Signature) (Date) (Witness) (Date) I give permission for Cape Fear Smiles to disclose information to the following individuals (please include relationship to you): For Office Use Only 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 Rights ReservedReproduction and use of this form by dentists and their staffs 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. This Form is education only, does not constitute legal advice, and covers only federal, not state, law (August 14,

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