I understand that I have certain rights to privacy regarding my protected health information. These rights are given to

me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this

consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

• Obtaining payment from third party payers (e.g. my insurance company);

• The day-to-day healthcare operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which

contains a more complete description of the uses and disclosures of my protected health information and my rights

under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may

contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request

restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health

care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are

then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However,

any use or disclosure that occurred prior to the date I revoke this consent is not affected.

CONSENT FOR TREATMENT: I hereby grant authority to the dentist(s) in charge of the care of the patient whose name

appears on this Health History form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation and

intravenous sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and

treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics and/or

drugs.

YOUR RIGHTS: You have the right to have access and/or copies of your PHI records at any time. You have the right to

request additional restrictions on your PHI, and we will do so unless legally bound otherwise. You have the right to

refuse to sign the consent form, or to rescind your consent.

NOTICE OF PRIVACY POLICIESHealth Insurance Portability Accountability Act (HIPAA),

1996 http://www.hhs.gov/ocr/hipaa/finalreg.html

NAME:

ADDRESS:

PHONE:

Signature Date

Personal Representative's Name: Relationship:

If this consent is signed by a personal representative on behalf of the patient, complete the following:

ABOUT YOU INSURANCE COVERAGEDate:

Primary

Secondary

SPOUSE INFORMATION EMERGENCY CONTACT

Isurance Co. Name:

Isurance Co. Name:

Employer:

Birthdate:

Isurance Co. Phone #:

Isurance Co. Phone #:

SS #: Name:

Group # (Plan/Policy):

Group # (Plan/Policy):

Insured's Name:

Insured's Name:

Person Responsible for Account: Relation:

Relation:

Relation:

Contact #: Cell #: SS#: Work #:

Insured's ID#:

Insured's ID#:

Employer:

Insured's Employer:

Billing Address:

Insured's Employer:

Are you financially responsible for this account?

DOB:

DOB:

Contact no.:

E-mail Address:

Employer:

Other family members seen by us:

Whom may we thank for referring you?

Previous/Present Dentist:

Last Visit Date:

Occupation:

Home Address:

Age:Birthdate:

I prefer to be called:

Social Security Number:

NameLAST FIRST MI MR MRS MS DR

HOUSE /APT. / CONDO #

CITY STATE ZIP

How do you prefer to be contacted? E-mail Phone Text

Gender: Male Female Gender neutral

Dental Coverage:

Dental Coverage:

His/ Her Name: In an event of emergency, is there someone weshould contact?

Yes No

Yes No

Yes No

Single Married Divorced Widowed Seperated

CONTINUED ON BACK

GENERAL INFORMATION

MEDICAL HISTORY

Have you ever taken Fosamax, or any other bisphosphonate?

Phone No.:

Week#:

Date of last visit:

For Women:

Please list any serious medical condition(s) that you have ever had:

Please list any other drugs/ material that you are allergic to:

Are you allergic to any of the following?

Please list all:

If yes, why?

Physician's Name:

Have you ever had any of the following conditions?

Are you pregnant?

Are you nursing?

Your current physical health is:

Are you currently under the care of a physician?

Good Fair Poor

Do you have a personal physician?

Yes No

Are you taking any prescription/over-the-counter or herbal supplement drugs? Yes No

Yes No

Yes No

Yes No

Yes No

HIV + / AIDS

Tetracycline

High Blood Pressure

Penicillin

Hospitalized AnytimeKidney ProblemsLiver DiseaseLow Blood PressureMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation Treatment

Rheumatic FeverSeizuresShinglesSickle Cell Disease/TraitsSinus ProblemsStrokeThyroid ProblemsTuberculosis (TB)UlcersVenereal Disease

Artificial Joint/ Heart Valve

Blood TransfusionCancer/ ChemotherapyColitisCongenital Heart DefectDiabetesDifficulty Breathing

Emphysema

Erythromycin

Epilepsy

Jewelery

Fainting Spells

Latex

Frequent HeadachesGlaucomaHay FeverHeart AttackHeart MurmurHeart SurgeryHemophilia

Alcohol/ Drug Abuse

Aspirin

Anemia

Codeine

Arthritis

Dental Anesthetics

Asthma

Herpes / Fever Blisters

Metals

Hepatitis

GENERAL INFORMATION

DENTAL HEALTH COSMETIC EVALUATION

Why have you come to the Dentist today? Do you like your smile?

Would you like to have whiter teeth?

What personal or professional benefits might yougain with a better smile?

Do you have any special occasions coming up?

Please add anything you feel is important:

Signature Date

Any serious problems with previous dental treatment or anydental emergencies?

Reason for changing dental practice (if any) ?

Do you feel that you have bad breath?

Are you currently in pain?

Do your gums feel tender/swollen?

What food causes you twinges of pain?

Do you chew on only one side of yourmouth?

Do you clench or grind your jaws whilesleeping or during the day?

Do your jaws feel tired?

Have you experienced pain/ discomfortin your jaw joint (TMJ/ TMD) ?

How often do you brush your teeth?

How often do you floss?

If yes, what part?

If yes, explain? :

What type of brush do you use?

Do you avoid brushing any part ofyour mouth because of pain?

When woud you like us to start treatment?

Approximate date of last dentist visit:

Please rate your smile from 1 to 10 :

(1= I hate my smile, 10= I love my smile)

Would you like to see what you would look like witha new and improved smile through Dental Imagingand Digital Photography?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Hot Cold

NoneSweet Sour

ManualPowered

Yes No

Yes No

Yes No

CONTINUED ON BACK

I understand that the information I have given today is correct to the bestof my knowledge. I also understand this information will be held in thestrictest confidence and it is my responsibility to inform this office of anychanges in my medical status. I authorize the release of information to insurance carriers and otherhealth care professionals who are involved in my care. I assign myinsurance benefits unless otherwise indicated. I have received a copy ofHIPAA Law and Dental Material form as well as releasing Dr. Chopra toutilize any dental Photographs for lecturing or educational purposes. I authorize the dental staff to perform any necessary dental services that Imay need during diagnosis and treatment with my informed consent. 

Our practice is HIPAA Compliant and committed to meeting or ecxeeding the standardsof infection control mandated by OSHA, the CDC and the ADA

GENERAL INFORMATION

PAYMENT OPTIONS FOR OUR PATIENTS

Payment in Full at Visit

No or Low-Interest Payment Plans

Estimated Co-payment at Visit

We believe it is important not only to provide the highest quality dental care, but to make this care affordable for ourpatients. Please ask us any question you may have. We are glad to be of assistance. We have made arrangements for ourpatients that allow payment to be convenient and flexible. We are committed to helping you receive the dental care youdesire and the most pleasant dental experience possible.

Pay with cash, check or credit card ( VISA, MasterCard, Discover or American Express)For amounts over $5000, we offer a 5% courtesy forpayment in full when you receive treatment.We will gladly process any insurance claim for your directreimbursement. Adjusted fee: $ Savings: $

Note to Patients with Insurance: We are happy to process any insurance claimas a service to you at no charge. Please keep in mind that any estimate that weprovide to you is only an estimate and that you are responsible for ll fees intheir entirety. We are proud that our fees reflect the time that the doctorspends with each patient as well as the overall quality of care and service. Ourfees are not based upon any insurance schedules, and are often aboveinsurance allowance.  I hereby authorize assignment of my insurance rightsand benefits directly to the provider for services rendered. I fully understandthat I am solely responsible for any balance not paid by my insurance company( if offered at this office).

Delinquent Accounts: Your account is considereddelinquent if the requested payment is notreceived by the tenth (10th) of the month. Ifpayment is not received, a late charge of 1.5 %per month ($1.00 minimum) will be assessed Theannual percentage rate is 18%. If your account isnot paid withing 90 days of the date of service andno financial arrangements have been made, youwill be responsible for legal fees, collectionagency fees, interest charges and any otherexpenses incurred in collecting your account.

Pay with cash, check or credit card ( VISA, MasterCard, Discover or American Express)With most insurance plans following benefit verification. Estimated co-pay*: $

For amounts over $3000 through CareCredit. We will gladly process any insurance claim for your direct reimbursement.

Monthly Payment: $

Credit Report Authorization: I, authorize Dr. Chopra to obtain my credit report inthe event that I request a payment plan for my treatment.

Signature Date

Signature Date

*We cannot guarantee this estimate and there may be abalance after insurance pays. Whenever choosing this option,we ask that you leave a credit card on file for any balance thatmay be owed.

I have read and understand the financial options Dr. Chopra and agree to the terms described in it.

We feel it is necessary to develop a rapport with our patients. Many new patients have had a past unpleasant

dental experience. It is crucial to us to know and understand your concerns. We are committed to taking the

time to get to know you, discuss your concerns, your fears and your dental expectation.

PLEASE HANDLE ME WITH CARE

Please place a check mark in the box next to the statement that concerns you or describes your problem.

I gag easilyI feel out of control when I lie down for a long time, and I feel uncomfortable about what you will sayabout my teeth and hygiene.Pain relief is a top priority for me.

I don't like shots ( or I've had a bad reaction to shots).

Please tell me what I need to know about my mouth in order to make an informed decision.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.I have difficulty listening and remembering what I hear while sitting in a dental chair.

I have health problems and question that we need to discuss.

I am interested in conscious sedation ( nitrous oxide with oxygen).

I ask that you honestly inform me of all my dental problems. I want you to make me aware of the bestquality dentistry available today. Then we can discuss how I can make healthy choices that will work withinmy budget. I also want to know all the pain relief options available to me, how each dental procedures willwork and how much of my time will be required.

Partnership Pact:

I don't like the sound of that tool that makes the picking and scraping noise. It is like someone isscratching fingernails on a blackboard.

Patient's Name :

COMFORT MENU

Your comfort is our priority !

We provide a variety of services to ensure that you are comfortable at all times.

Please circle the options that will be best preferred by you.

Is there anything else we can do to make your visit pleasant and comfortable?

Please let us know your choice of movies/ TVshows/ music and we can make it available onyour next visit.

iPod with personalizedplaylists

Cable TV / Movie

Complimentary Wi-fiAnalgesics: Tylenol / Advil / Other

Nitrous Oxide (laughing gas)

Mild sedative (oral medication)

It helps rapidly reverse the

effects of local dental anesthetic

SedationDentistry:

Oraverse:

Blankets to keep you warm and relaxed.

Pillows to provide extra comfort for neck or back.

Paraffin Wax treatment to help you relax.