entat Ins' Referred by: Patient Personal Information Title Last, First Address Birth Date Marital Status Home # Cell # Age M/F Work # DL # SSN

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1 Referred by: Patient Personal Information Title Last, First Address City, State Zip Birth Marital Status Home # Cell # entat Ins' Age M/F Work # DL # SSN Person responsible/guarantor for paying bills Title Birth Last, First Marital Status Address Home # Cell # City, State Zip Age M/F Work # DL # SSN Do you have Primary Dental Insurance Yes/No Secondary Dental Insurance Yes/No Group #/Name Insurance Name Employer Name Subscriber Last, First Subscriber Address City, State, Zip Relationship to Patient Subscriber ID Birth Patient Medical Information Allergic To Ch eck, if applicable 10 r_i E No known allergies No Known issues t_j Aspirin AIDS/HIV infection Barbiturates/Sleeping Pills Alcohol/Drug Abuse Codeine Anemia/Leukemia Erythromycin Anorexia/Bulimia Iodine Arthritis Latex Rubber Asthma/Hay Fever Local Anesthetics Blood Clotting Issues Metals Blood Transfusion Cil Group #/Name Insurance Name Employer Name Subscriber Last, First Subscriber Address City, State, Zip Relationship to Patient Subscriber ID Fainting Spells/Seizures Fever Blisters/Herpes Frequent Headaches Frequent Dry Mouth Gall Bladder Trouble Heart Attack/Stroke Heart Disease/Angina Premedicate STDs E.] Sinus Trouble Stomach Ulcers Thyroid Problems Tuberculosis Birth Heart Murmur Hepatitis/Jaundice High Blood Pressure ED Unusual Weight Loss Urinate Frequently No Ephephrine Bronchitis Hives/Skin Rash Shortness of Breath Penicillin Cancer/Tumor Joint Replacement on what date: Prior Hepatitis Cardiac Pacemaker Kidney/Bladder Trouble Sulfa Drugs Chest Pain Liver Disease Rheumatic Heart Disease Other Narcotics Color Blindness Mental Health Problems Contact Lenses Mitral Valve Prolapse Damaged Heart Value Persistent Diarrhea

2 Dental Questionnaire Name of Previous Dentist Phone Number of your last cleaning of your last exam of your last full series x-rays of last cavity detection (bitewing) x-rays Do your gums bleed while brushing or flossing? Are your teeth sensitive to hot, cold or sweets? Do you get frequent fever blisters, mouth ulcers or sores on your lips or your mouth? Have you ever had burning of the tongue or cracking of the corners of your mouth? Do you chew/smoke tobacco in any form? Have you had any head, neck or jaw injuries? Do you notice popping, clicking or soreness of the jaws or points just in front of the ears? Do you clench or grind your teeth? Have you ever had orthodontic treatment? If yes, date of placement Do you wear dentures or partials? If yes, date of placement Are you happy with your dentures? Are you having any specific problems with your teeth, gums or mouth at this time? Are you happy with your smile? Do you have problems with teeth/fillings breaking? Do you regularly use dental floss? Have you ever been told you have Pyorrhea? Do you have difficultly in opening your mouth widely? Do you have an unpleasant taste or odor in your teeth/mouth? Does food catch between your teeth? Do you want to learn to control dental disease and retain your teeth? E n CONSENT The undersigned hereby authorizes Dr Moore (hereafter known as Doctor) to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with Name of Patient: And the undersigned further authorizes and consents that the Doctor choose and employ such assistance as deemed fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that the responsibility for payment of dental services provided in this office for myself is mine, and that payment is due and payable at the time services are rendered. Patient Witness

3 Medical Questionnaire Family Physician Phone # Are you currently under care of a Physician? If yes, what is the condition being treated? Have you had any serious illness, operation or been hospitalized with the last 5 years? If yes, what illness or problem? Are you currently taking any medications? If Yes, which? Have you taken bisphosphonates? (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast) Have you ever taken the diet control drug Fen-Phen? Do you use alcoholic beverages? Do you smoke? Women Only Are you pregnant? If yes, what is your due date? Are you currently nursing? Do you have menstrual period problems? Are you on hormone replacement therapy? Are you on birth control pills/fertility drugs? Additional Comments Any disease, condition or problem not listed? Senior Citizens Are you in a wheel chair? By signing below, I certify that all of the above information is true to the best of my knowledge. Patient/Guardian Signature Witness

4 R aj) \S4- Dentat Insr Star Dental Institute 2620 TENDERFOOT HILL ST, SUITE 210 COLORADO SPRINGS, CO ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse To Sign This Acknowledgement office's Notice of Privacy Practices., have reviewed a copy of this Please Print Name Signature For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice Of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify) 1

5 \-S4- dental Star Dental Institute 2620 TENDERFOOT HILL ST, SUITE 210 COLORADO SPRINGS, CO FINANCIAL POLICY FOR OUR PATIENTS Great dental treatment is vital to the quality of your life and we are sensitive to your concerns about paying for it. We will gladly discuss the payment options we have available before beginning any treatment. Please review the following payment opportunities. DENTAL INSURANCE: Our office will work with you to maximize your available benefits and diligently follow up on claims to secure payment. In return we ask that you pay your deductibles and copays on the day treatment is rendered. Most insurance plans do not cover 100% of our fees. We will do our best to estimate your patient portion but please understand these estimations cannot be guaranteed. Your insurance is an agreement between you and your insurance company and you are ultimately responsible for all charges. We will do everything possible to help you receive your benefits, but if your insurance does not pay their portion within 60 days of your treatment, you are responsible for full payment of the balance at that time. Deposits: An appointment deposit is required at the time of scheduling treatment. PAYMENT OPTIONS: 1. We offer a 5% discount for treatment that is paid in full in advance of treatment. A 3% discount is offered for treatment that is paid in full in advance when paid by credit card. A 10 % down payment is made by cash check or credit card at the time the appointment is scheduled. 2. We accept cash, checks and VISA, MasterCard, Discover and American Express. 3. We offer outside financing through Care Credit and Arch Advantage. Ask us for the latest details on their low and no interest rates options and number of months to pay options. 4. We offer an appointment based plan that includes a down payment and two equal payments made at the time of appointments. 5. We offer a 10% Senior Discount to patients 60 years or older who pay at the time of service. I understand the Financial Policies of Star Dental Institute. Signature of Responsible Party Printed Name

6 5?"91- Den tat Ins Medicaid Consent - Authorization for Dental Treatment I hereby authorize Dr. Gary Moore DDS and his associates to provide dental services, prescribe, dispense and/or administer any drugs, medicaments, antibiotics, and local anesthetics that he or his associates deem, in their professional judgment, necessary or appropriate in my care. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions (tooth removal). The most common risks can include, but are not limited to: Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest. I realize that it is mandatory that I follow any instructions given by the dentist and/or his/her associates and take any medication as directed. I understand that NO GUARANTEES OR WARRANTIES as to the results of treatment can be made with any dental treatment given to me. Alternative treatment options, including no treatment, have been discussed and understood. A full explanation of all complications is available to me upon request from the dentist. I grant my permission to you or your assignee to telephone me at home or at my workplace to discuss matters related to this form. I also agree to let this office leave messages concerning appointments and/or results on my answering machine or with family member. I authorize the dentist or his designees to release financially identifiable information and treatment descriptions and information, either electronically, by facsimile or in paper form to my insurance carrier or any related entities that require such information to be submitted. I acknowledge that I have reviewed a copy of this office's Privacy Policies. I agree to disclose to the dentist names of any individuals with whom I authorize the dentist to discuss my dental care. I authorize the doctor, and/or such associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and for administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, muscle soreness, and temporary or rarely, permanent numbness. I understand that occasionally needles break and may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes and facial tissues and cause temporary irritation. I understand that as part of the dental treatment, including preventative procedures such as cleanings and basic dentistry, including fillings of all types,

7 teeth may remain sensitive or even quite painful both during and after completion of treatment. Dental materials and medications may trigger allergic or sensitivity reactions. All claims and disputes arising under this Agreement that cannot be resolved by the parties must first be submitted to a mediator in an attempt to resolve the dispute outside of litigation. Any such mediation shall begin within seven days from the request for mediation by either party. The mediation must be completed within ten days thereafter. The plaintiff will bear the cost of mediation. If the parties do not submit to this mediation in good faith, as determined by the mediator, the parties may not proceed with any other remedies under this Agreement. I am aware the doctor does use amalgam (mercury) fillings to restore teeth. I understand my insurance may or may not cover composite (white) fillings; I am responsible to pay the difference if I choose to have more expensive white fillings or crowns. After lengthy appointments, jaw muscles may also be sore or tender. Holding one's mouth open can, in a predisposed patient, precipitate a TMJ disorder. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is also possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required. I understand that as part of dental treatment items including, but not limited to crowns, small dental instruments, drill components, etc. may be aspirated (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require bronchoscopy or other procedures to ensure safe removal. I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past,. I understand that taking the any drugs prescribed for the prevention of osteoporosis, heart or systemic problems, such as Fosamax, Boniva, Actonel, and blood thinners such as aspirin may result in complications of non-healing or very slow healing of the jaw bones following oral surgery or tooth extractions. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions. I understand that I am solely responsible for the full payment of services received from this office on ANY and ALL procedures that are uncovered and/or denied by MEDICAID. Patient Name (please print): Patient Signature: Witness:

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