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Hady Attar, DDS DENTAL PATIENT INFORMATION

WELCOME

Thank you for selecting Hady Attar, DDS. To help us meet all of your dental needs, please complete this form as accurately as possible. 1) PATIENT INFORMATION This appointment is for Yourself 0 Your Child Patient Full Name Birth Date Age Driver's License# Address Full Time Student 0 Yes 0 No Employer Current Physician

Current Physician Phone

2) TELEPHONE 8c EMAIL Home Phone Work Phone E-mail

Cell Phone Best Time to Call

In the event of an emergency, who do we contact? Name Home Phone

Relationship Work Phone

3) RESPONSIBLE PARTY Who is responsible for this patient? Full Name Social Security # Birth Date Age E Male El Female Address City State Zip Employer Occupation Home Phone Work Phone

4) INSURANCE INFORMATION Dental Coverage E Yes II No Insured's Name Social Security # Insured's Social Security # Birth Date Insurance Co. Name Insurance Co. Phone

5) DENTAL HISTORY Why have you come to the dentist today? Date of last Dental Visit? Do you require premedication before dental treatment 9 Yes No Are you currently in pain'? Yes No Do your gums ever bleed? Yes No Have you ever had difficulties associated with any previous dental work? Yes No Have you ever experience pain in your jaw joint (TMJ/TMD)9 Yes No Do you floss on a regular basis? Yes No

Initial I authorize Hady Attar, DDS to use my photos for educational purposes in the office, website and ect.

Hady Attar, DDS

fa) MW1CAL 1-11STORY Do you consider yourself in good medical health'? Yes No Have you had previous skin reactions to jewelry or know of any allergies to metal? Yes No Have you had abnormal bleeding associated with previous extractions, surgery or trauma? Yes No Have you been hospitalized or had serious operation or illness within the last 5 years? Yes No Are you taking any medication? Yes No If so, please list here? Are you allergic to any of the following? EPenicillin ECodeine [Aspirin ELidocaine or Marcaine E Nitrous oxide gas 0lodine 0Dental Anesthetics EErythromycin El Latex 00ther: Have you ever had any of the following medical problems? Please check only those that apply: E Abnormal Bleeding E Fainting or Dizziness E Kidney Problems 0 Alcohol/ Drug Abuse E Frequent Headaches E Liver Disease/ Problems 0 Anemia 0 Glaucoma E Low Blood Pressure Update Medical History: 0 Arthritis El Hay Fever E Nervous Disorder E Artificial Joint E Heart Attack Disease 0 Pacemaker Patient Sig: or

D ate: Asthma E E Heart Murmur/ Surgery 0 Rheumatic Fever

11 Cancer or Leukemia 0 Hemophilia 0 Seizures Doctors Sig: E Diabetes 0 Hepatitis 0 Shingles Date: 0 Difficulty Breathing E Herpes/ Fever Blisters 0 Sinus Problems 0 Emphysema E High Blood Pressure 0 Stroke E Epilepsy 0 HIV Positive/ AIDS El Thyroid Problems

Patient Sig: E Ulcers 0 Venereal Disease E Stomach Problems Date: E Blood Disorder E Tumors 0 Steroids 0 Implants E Heart Failure 0 Tuberculosis (TB) Doctors Sig: E Artificial Heart Valve 0 Cough 0 Bruise Easily Date: 0 Blood Transfusion 0 Sickle Cell Disease CI Cold Sores 0 Angina Pectoris 0 Congenital Heart Lesions 0 Scarlet Fever E Hepatitis A (Infectious) E Hepatitis B (Serum) E Psychiatric Treatment E High Cholesterol E STD / VD (Syphilis, Gonorrhea) 0 Yellow Jaundice E Depression/Anxiety E Other: Woman Only: Are you pregnant? Yes No If so, how many weeks? Are you nursing? Yes No _ Are you taking birth control? Yes No

7)REFERRAL INFORMATION Who may we thank for referring you to our practice?

LI Patient or Friend E Relative CI Work E School U Post Card E Dental Office E Yellow Pages CI Newspaper E Driving By/ Walk In 0 Other:

Name of person or office referring you to our practice:

8) ACKNOWLEDGEMENT & AUTHORIZATION The undersigned hereby authorized the doctor to take radiographs, 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 indicates with (name of patient) and further authorize and consent that doctor choose to employ such as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I certify that I have read and understand the above. I acknowledge that my questions have been answered truthfully and to the best of my knowledge. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. SIGNATURE: DATE:

DOCTOR SIGNATURE:

Hady Attar, DDS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

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

I, , have received a copy of this office's Notice of Privacy Practice.

(Please Print Name)

(Signature or Patient Guardian)

(Date)

For Office use Only

We attempt to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

O Individual refused to sign

O Communication barriers prohibited obtaining the acknowledgement

O An emergency situation prevented us from obtaining acknowledgement

O Other (Please Specify)

© 2002 American Dental Association All Rights Reserved

Reproduction and use of this form by dentist 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 advise and covers only federal, not state, law ( August 14, 2002)