WELCOME TO COMFORT DENTAL PATIENT REGISTRATION & HEALTH HISTORY FORM

All Comfort Dental offices are owned and operated by independent, dentist-owned franchisees of Comfort Dental Group, Inc. Questions or comments about this office should be addressed to the dentists in this practice.

Comfort Dental Group, Inc. does not own or operate any dental practices.

PATIENT (OR RESPONSIBLE PARTY, IF PATIENT IS A MINOR)

PLEASE PRINT CLEARLY Last Name First Name Initial Cell Phone Number Home Phone Number

Address City State Zip

Birth Date Age Employer How Long Work Phone Number / Ext.

Occupation Business Address City State Zip

Driver's License Number Social Security Number Email Address Gender • Male

• Female

SPOUSE ❑ Male

❑ Female

Last Name First Name Initial Cell Phone Number Home Phone Number

Birth Date Age Employer How Long Work Phone Number / Ext.

Occupation Business Address City State Zip

CHILD (IF CHILD IS THE PATIENT)

Last Name First Name Initial Home Phone Number

Address City State Zip

Birth Date Age Sex

M F

School City Grade

DENTAL INSURANCE Insurance Name Address / City / State / Zip

Name of Policy Holder Policy Holder's Social Security # Member # Group #

Policy Holder's Employer Policy Holder's Date of Birth

Additional Insurance Company Name Address Policy Holder's Social Security # Group #

PERSON TO CONTACT IN CASE OF EMERGENCY:

Name Address

Phone

Is another member of your family a patient at our practice? ❑ YES 1:1 NO

Name 1/2016 This office owned & operated by an independent Franchisee

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C:ieNnic,rt

NO SHOW POLICY

Our goal here at Comfort Dental is to provide quality service to all of our patients in a timely manner. Failure to keep scheduled appointments is costly to both the clinic and you as a patient.

This letter is to inform you of our policy concerning "No Shows". Patients who are unable to keep their appointments are requested to give 24-hour notice prior to their appointments. We realize this is not always possible and the practice will consider each individual case. Providing such notice allows the clinic time to offer other persons the opportunity to see our providers, thus using the time more efficiently.

If an established patient fails to provide notice, it will be necessary to charge them a $25.00 fee that will be billed to his/her account. If a patient has confirmed his/her appointment and fails to keep that appointment, there will be a $25.00 fee billed to his/her account. If a patient fails to keep his/her appointments on a regular basis, or has missed 3 consecutive appointments, he/she will be considered dismissed from the practice, and a letter of dismissal will follow. I have read and understood this policy, and accept the responsibility of its terms.

Patient Signature

Date

Cekeimbrt INFORMATIONAL PURPOSES ONLY

GENERAL CONSENT

Thank you for choosing our office for your dental care. We will work with you to help you achieve excellent oral health. While recognizing the benefits of a pleasing smile and teeth that function well, you should be aware that dental treatment, like treatment of any other part of the body, has some inherent risks. These are seldom great enough to offset the benefits of treatment, but should be considered when making treatment decisions.

Benefits of dental treatment can include: relief of pain, the ability to chew properly, and the confidence and social interaction that a pleasing smile can bring. Nonetheless, there are some common risks associated with virtually any dental procedure, including:

1. Drug or chemical, reaction. Dental materials and medications may trigger allergic or sensitivity reactions.

2. Long-term numbness (paresthesia). Local anesthetic, or its administration, while almost always adequate to allow comfortable care, can result in transient, or in rare instances, permanent numbness.

3. Muscle or joint tenderness. Holding one's mouth open can result in muscle or jaw joint tenderness, or in a predisposed patient, precipitate a TMJ disorder.

4. Sensitivity in teeth or gums, infection, or bleeding. 5. Swallowing or inhaling small objects.

While we follow procedural guidelines which most often lead to a clinical success, just like m any other pursuit in health care, not everything turns out the way it is planned. We will do our best to assure that it does. Please feel free to ask questions in regard to all dental procedures that are recommended to you.

I have read and understand the statement on this page:

Patient's Signature Date

Parent's Signature (if minor patient) Date

Cmfat ote ed teal

Financial Policy Thank you for your trust in our office. Our usual and customary fees apply equally and witho ut prejudice to everyone. For your convenience we accept cash, personal checks and credit cards

To our patients with insurance It is the responsibility of the patient to know and understand their insurance coverage. You are responsible for the entire account. When all necessary information is provided to bill an insurance company we will do our best to collect payment for you. We can give you an estimate of your portion based on benefit's the insurance company has given us, but again this is only an

estimate. Your final portion will be determined by your insurance company. If no payment is made by your insurance company within 90 days you are responsible for the entire account bill. Verification of eligibility and benefits is determined once the insurance company receives our claim. If, at that time, the claim is denied, the bill is the total responsibility of the patient.

Without a copy of your card from your current dental carrier we will be unable to be sure of whet her or not they will pay on a claim from our office. If it is determined that your insurance carrier will not pay on a claim from our office, the bill is due from you in full at that time.

When an insurance company requires a pre-authorization to proceed with treatment, our office will send the paperwork and notify the patient of the results. If surgery is scheduled before this pre-treatment estimate has been approved the patient may elect to pay full price on the day of the surgery.

The estimate portion due from you is due on the day of services or your appointment will be rescheduled.

To our minor (under 18) patients Minor patients will be seen when they are accompanied by their parent or guardian. The parent who accompanies the minor is the one who will be billed in full for the treatment given. We will not bill a missing parent due to a divorce or any other complication. Please make arrangements before treatment so this will not be a problem.

Cancellation policy A 24 hour cancellation is required to avoid a $25.00 charge

Service charge If I do not pay the balance due within 10 days of the monthly billing date, a service charge of $5.00 will be added to the account each billing cycle. I promise to pay any legal collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.

I have read and understood the financial policy. I am responsible for this account whether or not paid for by insurance.

(Signature of patient / guardian) (Date) CD-27

CmfQ2rt 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 Notice 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 Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice 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 Notice 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 Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

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 Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. 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. CDG-23

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 voicemail messages, postcards, or letters).

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 Notice. 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 Notice. If you request copies, we will charge you $25.00 for X-ray copies and $0.25 for each copied page of your health information. Postage may be charged 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 Notice 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, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based 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 Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice 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 Notice. 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.

Provider Contact Office:

Doctor Representative: Office Manager*

Telephone . Fax:

Address:

© 2002 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)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowedgement*

, have received a copy of this

office's Notice of Privacy Practices.

Please Print Name

Signature

Date

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

❑ Communications barriers prohibited obtaining the acknowledgement

❑ An emergency situation prevented us from obtaining acknowledgement

❑ Other (Please Specify)

All Comfort Dental offices are independently owned and operated.

0 2002 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).

CDG-24