I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge. Patient’s Signature Date Dr’s. Signature/Medical History Review Date

Patient’s Signature Date Dr’s. Signature/Medical History Review Date

Do you have a history of: Y N Y N Y N Y N

Rheumatic Fever Asthma Thyroid Disease Alcoholism

Heart Murmur Allergies or Hives Epilepsy or Seizures Psychiatric Treatment

Mitral Valve Prolapse Anemia Fainting or Dizzy Spells Mouth sores/growths

Diabetes Asprin/Anticoagulant Therapy Ulcers or Stomach Problems Teeth Grinding/Clenching

Pace Maker/Heart Surgery Venereal Disease Arthritis Pain in your jaw (TMJ)

High Blood Pressure HIV Positive/Aids Latex Allergy Any type of Implant

Low Blood Pressure Blood Transfusion Sinus Problems Any type of Transplant

Heart Problem ( ) Excessive Bleeding Cancer (Type: ) Any Artificial Hip, Knee or other Joint

Stroke Hepatitis (Type: ) Chemotherapy Other Disease or Illness:

Lung Disease Liver Disease Radiation Treatment

Breathing Problems Kidney Disease Use of Tobacco Products

Tuberculosis (TB) Dialysis Drug Addiction

Women Y N Y N

Is there a possibility of pregnancy? Are you nursing?

Estimated Delivery Date: / / Are you taking any birth control prescriptions?

NOTE: Antibiotics ( such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Patient’s Name: ________________________________ Date of Birth: ____________________ Last Physical Date: __________

Acct. #_________________ Physician’s Name & Phone #: __________________________________________________________

Reason for today’s visit? ______________________________________________________________________________________

Work Related Injury? (circle) Yes No Have you been under the care of a physician? (circle) Yes No

Date of last dental visit: _________________________________________Have you ever been hospitalized? (circle) Yes No

Date of last dental x-rays: _____________________________ Ever had Novocaine or other local anesthetic? (circle) Yes No

If wearing dentures, age of dentures:

____________________________________________________________________________

Are you taking or have taken any steroid/cortisone therapy in the last 2 years? (circle) Yes

No

Are you taking or have taken Oral Bisphosphonates, e.g., FOSAMAX, ACTONEL, BONIVA, or IV Bisphosphonates, e.g.,

ZOMETA, AREDIA? (circle) Yes

No

Taken for how long?

________________________________________________

Have you taken antibiotics prior to dental procedures in the past? (circle) Yes

No

Have you had an adverse reaction or become ill to penicillin, aspirin, codeine, local anesthetics, latex, metals,

or any other medication? (circle)

Yes

No

List any medications you are allergic to:

1.

________________________2.

________________________ 3.

_____________________4.

_____________________________

List any medications you are taking including non-prescription drugs including herbals/vitamins:

1.

________________________2.

________________________ 3.

_____________________4.

_____________________________

Health Information

Are you interested in new dentures? (circle) Yes No

Are you interested in tooth whitening?(circle) Yes No

ASPEN DENTAL TAKES YOUR ORAL HEALTH VERY SERIOUSLY. BUT BEFORE WE START YOUR TREATMENT WE NEED SOME BRIEF INFORMATION ON YOUR MEDICAL HISTORY AS IT MAY AFFECT

DENTAL TREATMENT. ALL INFORMATION IS CONFIDENTIAL

DATE

DATE

DATE

DATE

DATE

DATE

DATE

PATIENT SIGNATURE

PATIENT SIGNATURE

PATIENT SIGNATURE

PATIENT SIGNATURE

PATIENT SIGNATURE

PATIENT SIGNATURE

DATE

PATIENT SIGNATURE

PATIENT SIGNATURE

Patient Acknowledgements, Agreements and Authorizations Aspen Dental is committed to providing all patients with exceptional service and care. If you feel you have an issue that cannot be resolved by your Aspen Dental office team, please call our Patient Satisfaction Hotline at 1-866-273-8606 or email us at patientservices@aspendental.com. We will respond to you as quickly as possible, but always within two business days from your initial contact with us. We are committed to your complete satisfaction and we look forward to resolving any patient satisfaction issues quickly and courteously. I. Treatment Plan Estimates Aspen Dental prepares a Treatment Plan Estimate so that patients can understand the estimated costs of their recommended treatment prior to its start. The Treatment Plan Estimate is a good-faith attempt to predict the cost of your treatment based on the facts known to Aspen Dental when the estimate is made. As your treatment progresses, your dentist may determine in consultation with you that different or additional treatment is necessary and your financial responsibility may change. If you have dental insurance, it is important to understand that your actual insurance benefits may differ from the benefits estimated in your Treatment Plan Estimate. Your Treatment Plan Estimate of insurance benefits is based on information provided by your insurance company and by you. It is an estimate and your insurance benefits may be higher or lower than estimated. In all cases, you are responsible for amounts not covered by your insurance, unless prohibited by law or contractual agreement. In all cases, we encourage all patients with insurance to refer to their member handbooks or to call their plan administrators with any questions or concerns relating to specific benefits. II. Predetermination of Insurance Benefits If you have insurance benefits, you may have the option to seek a Predetermination of Benefits before you proceed with any treatment. Predetermination of Benefits is a process whereby your insurance company or plan administrator tells you in advance of treatment what procedures may be covered by your insurance plan, the amount the insurance company may pay toward those procedures, and the amount you may be required to pay. Requesting a Predetermination is like submitting a claim before the dental procedure or service has taken place. Because the Predetermination comes directly from your insurer or plan administrator, the risk of error as to your coverage is reduced. If your treatment includes extensive or complex services, such as bridges, crowns, dentures or periodontal work, a Predetermination may be particularly helpful to allow you to appropriately budget for the services or discuss any potential alternative treatment that may be available, if necessary. The Predetermination of Benefits process gives you useful information about what services may be covered. However, your insurer will inform you that a Predetermination of Benefits is not a guarantee of coverage. A Predetermination sets forth your expected benefits based on the information available to the insurer at the time

the Predetermination is prepared. The Predetermination may not consider, for example, a prior claim submitted by another dentist for services provided to you, changes in your coverage that occur after the Predetermination is made but before the services actually are provided, or the insurance company’s subsequent opinion that a condition could have been treated by a less costly alternative to the service provided by your dentist. The time it takes to receive a Predetermination from your insurance company or plan administrator can vary, from as few as two weeks to as many as eight weeks. The decision to seek a Predetermination of Benefits or to proceed with treatment immediately is your own, unless your plan requires otherwise. Please inform the Office Manager if you would like to request a Predetermination of Benefits from your insurer. III. Payment Policy In all cases, Aspen Dental patients agree to the following payment policies:

• Payment in full of the estimated patient portion of the fees is due no later than when services are rendered. • For comprehensive treatment plans requiring multiple office visits, Aspen Dental requires a minimum deposit of 60% of the total estimated patient portion of the fees at the start of treatment. • Patients are always responsible for amounts not covered by insurance, regardless of whether the original estimate included an expected insurance benefit, unless prohibited by law, or unless Aspen Dental has a contractual agreement with my plan prohibiting all or a portion of such charges. • Patients may, at their discretion, elect to pay in full, in advance for comprehensive treatment plans. Refunds for unused credit balances will be issued pursuant to Aspen Dental’s refund policy as stipulated in section IV, below.

IV. Refund Policy You may discontinue treatment and request a refund from Aspen Dental at any time. Aspen Dental will refund any amount paid for treatment that you did not receive, except when Aspen Dental’s policy for Interrupted Services, set forth in section VI, applies. All Refunds will be processed back to the original form of payment, except cash payments will be refunded by check. In all cases, credit balances existing on accounts after 180 days of inactivity will be refunded through the original form of payment, except that cash payments will be refunded by check, and account holders will be sent a letter notifying them of the refund. How to Request a Refund

Contact your local office and request a refund Email refund request to: refundrequest@aspendental.com Mail refund request to: Aspen Dental Management, Inc.

Attn: Refund Processing P.O. Box 3126 Syracuse, NY 13220

All Refunds will be processed back to the original form of payment, except cash payments will be refunded by check. Cash or Check Payment Refunds

Account Holder Refund Request – Upon receipt of a request for a refund, Aspen Dental will confirm all payments by check have cleared the bank (may take up to 15 business days). Once the credit balance is confirmed, Aspen Dental will issue a refund check within 10 business days.

Account Inactivity Automatic Refund – If an account is inactive for 21 days with no scheduled appointments, Aspen Dental will inform the account holder in writing that they may request a refund of a credit balance.

Major Credit Card Refunds Any refund of payment originated through a credit card company must be refunded to the originating credit card account. Please contact your credit card company for more information regarding their refund policy.

Account Holder Refund Request – Aspen Dental will issue credit card refunds within 3 business days. It may take up to 7 business days for the credit card company to post the payment to the cardholder’s account.

21 Day Automatic Refund of Patient Deposit with No Account Activity / No Scheduled Future Appointment – Aspen Dental will automatically refund outstanding credit balances to the originating credit card holder’s account. A letter is sent by Aspen Dental to the account holder detailing the refund.

Third Party Lender Refunds Any refund of payment originated through third party lenders must be refunded to the original account. Please contact the third party lender for more information regarding their refund policy as processing of refunds may not be reflected on an account for up to 2 billing cycles.

Account Holder Refund Request – Aspen Dental will issue third party lender refunds within 3 business days.

21 Day Automatic Refund of Patient Deposit with No Activity / No Scheduled Future Appointments – Aspen Dental will automatically refund the outstanding credit balance to the original third party lender account. A letter is sent by Aspen Dental to the account holder detailing the refund.

V. Patients with Dental Insurance Patients with insurance agree to Aspen Dental’s Payment Policy, as stated above, subject to the following:

A) In Network: If Aspen Dental is a participating provider in your plan network, your insurer may

impose requirements on Aspen Dental that affect your financial responsibility for treatment. For example, Aspen Dental may be required to receive approval from you in advance of treatment for non-covered services or may charge you only your co-payment at the time covered services are provided. In all cases, Aspen Dental will bill you pursuant to the terms of its agreement with your insurer.

B) Out of Network: Even if Aspen Dental is not a participating or in-network provider with your insurance plan, we will reduce your payment or deposit by your estimated insurance benefit if you assign the benefits to Aspen Dental. If the insurance plan will not pay benefits directly to Aspen Dental, you will bear full financial responsibility for your treatment plan, according to our payment policy. C) Insurance Discounts: Insurance companies often negotiate discounts with Aspen Dental for services provided to their plan members. If your benefit limits are exceeded, Aspen Dental will charge additional services at the discounted rate only if required to do so by your insurer.

VI. Treatment Cancellation and Interrupted Services Charges Patients requiring crown or bridge services may cancel treatment with no charge prior to natural teeth being prepared or altered for the prosthetic. Once tooth preparation occurs, patients are liable for the estimated full cost of the services even if they choose not to complete treatment. VII. Accepted Forms of Payment Aspen Dental accepts cash, personal checks, Visa , MasterCard , American Express , Discoverr , assigned insurance benefits and approved third-party financing. VIII. Third-Party Financing Aspen Dental offers treatment financing through non-affiliated, third-party lenders (such as CareCredit / GE Money). Aspen Dental pays these companies fees on a sliding scale for making loans available to patients and for the lender’s cost of servicing these loans. As the aggregate amount of care financed through these lenders increases, the fees they charge Aspen Dental decrease. This sliding scale pricing arrangement does not affect your loan amount or the cost of your treatment. Based on the approved credit limit determined by the third party lender the patient may elect to make full or partial payment when treatment is started and is obligated to make payment arrangements for any remaining balance prior to completing treatment. X. Denture Warranty A warranty card will be provided with your purchase of full or partial dentures.

ComfiLytes® dentures are eligible for FREE annual professional cleaning and inspection. All of our high-quality ComfiDents® dentures come with a warranty as specified below.

ComfiLytes®: 7-Year Warranty

NaturaLytes®: 3-Year Warranty Classic: 1-Year Warranty Basic: 6-Month Warranty FlexiLytes®: 2-Year Warranty FlexiLytes® Combo: 2-Year Warranty Cast Partial: 6-Month Warranty

However, we will not reconstruct, repair, reline or replace the denture, free of charge, due to any of the following: loss, discoloration, excessive wear (for example, excessive grinding of teeth), inappropriate use (for example, any use not prescribed by the dentist), neglect or abuse. Defects or damages resulting from any adjustment or alterations of your denture by someone other than an authorized Aspen Dental representative are excluded from coverage under our warranty agreement and will render it null and void.

For more information on warranties, please visit http://www.aspendental.com/dentures.warranty.html.

© Aspen Dental 2012

1. Notice of Privacy Practices (must be signed by ALL new patients). By signing below, I acknowledge that I have read Aspen Dental’s Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Signature________________________________________________Date__________________ (If patient is a minor or disabled, the Parent, Guardian or Attorney-in-Fact must sign above and complete the Responsible Party section below) 2. Payment, Insurance, and Financial Arrangement Policies (must be signed by ALL new patients). By signing below, I agree to the terms of the “Aspen Dental Patient Acknowledgements, Agreements, and Authorizations” document. Signature________________________________________________Date__________________ (If patient is a minor or disabled, the Parent, Guardian or Attorney-in-Fact must sign above and complete the Responsible Party section below) 3. Release of Information to Insurers and Assignment of Benefits (must be signed by all new patients with insurance and those who expect to obtain insurance). To the extent permitted by law, I consent to Aspen Dental’s use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to Aspen Dental of the dental benefits otherwise payable to me. Signature: _______________________________________________Date: _________________ (If patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete the Responsible Party section below) Responsible Party (If patient is under 18 or disabled) Circle One: Dr/Mr/Mrs/Ms/Miss First:___________________Middle:___________ Last:_________________________________Jr/Sr:______ Street: _____________________________________City:_________________ State: ______Zip: _________ Home Phone: (____) _______________Work Phone:(____) ____________Cell Phone:(____) ____________ Patient SSN: ________-_______-________Patient Date of Birth: _____/_____/_____Sex:(circle) M F Signature:__________________________________________________________Date:_________________

Revised 4/3/12

Patient Authorization for Release of Health Records to External Parties

I authorize the disclosure of information from my treatment records to:

Name of Recipient

Relationship to the Patient

I give authorization to disclose the following information:

All treatment information

Information specifically related to these treatment dates

Starting Date: End Date:

I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released. I may revoke this authorization by notifying Aspen Dental in writing.

Signature of Patient (or Patient Representative) Date

Printed Name of Patient (or Patient Representative)

Primary Insured Secondary Insured

Subscriber Name Subscriber Name

Subscriber SSN Subscriber SSN

Date of Birth Date of Birth

Relationship to Subscriber

Self Spouse Child OtherRelationship to Subscriber

Self Spouse Child Other

Employer Name Employer Name

Employer Phone Employer Phone

Insurance Company Insurance Company

Insurance Group # Insurance Group #

Insurance Phone # Insurance Phone #

*Please present card to receptionist to be photocopied*

General Information Employer Information

Drivers License Number: State: Exp. Date: Employer Name

Residence Status: Own Rent Live with others Employer Phone

Income Personal Reference

Source of Income: Employed Self-Employed □ Unemployed None Social Security □ Disability □ Investment Other:

Personal Reference Phone #

Nearest Relative Phone #

Monthly Hourly Yearly

Gross $Amount: Net $Amount:

Patient Information

Please Print Account Number:

Circle One: Dr/Mr/Mrs/Ms/Miss

First: Middle: Last: Jr/Sr: Street: City: State: Zip:

Home Phone: Work Phone:

Cell Phone:

Email Address: May we contact you by Email? (circle) Yes No

Patient Social Security Number: Patient Date of Birth: Sex:(circle) M F

Emergency Contact: Phone:

How did you hear about Aspen?

Newspaper Radio TV Internet Referral Other:

Insurance Information

Do you have Dental Insurance? (circle) Yes No Do you have Secondary Dental Insurance? (circle) Yes No

Payment Options At Aspen Dental, we understand that affordability is an important consideration in getting the denture and dental

treatment you need and deserve. We offer a variety of payment options so that your treatment is within reach. If you think you may be interested in one of our payment programs—and to save you time later on—just complete the section below. We’ll do the rest.

© 2008 Aspen Dental

Patient Information

Risk Management 2013

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND

HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. THE PRIVACY OF

YOUR HEALTH INFORMATION IS IMPORTANT TO US.

Our Legal Duty

Your Aspen Dental practice (“we”, “our”, “us”), like all other medical and dental practices, is 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 went into effect April

14, 2003, with the latest revision August 20, 2013 and will remain in effect until modified or replaced. 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

according to the means outlined in 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/dentist, dental auxiliaries, students and

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

Risk Management 2013

practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, dental

supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: • We may use Patient Information internally to offer goods and services we

believe may be of interest. We may use Patient Information to contact you to inquire or survey about the Patient

experience at the location(s) visited and the prospect of future services or improvements needed to continue as

your services provider. We may also create and use aggregate Patient Information that is not personally

identifiable to understand more about the common traits and interests of our Patients.

We may utilize one or more third-party service providers to send email or other communications to you on our

behalf, including Patient satisfaction surveys. These service providers are prohibited from using your email

address or other contact information for any purpose other than to send communications on our behalf. It is our intention to only send email communications that would be useful to you and that you want to receive. When you provide us with your email address as part of the registration or appointment setting process, we will place you on our list of patients to receive informational and promotional emails. In addition, patients and visitors to our website are given the opportunity to “opt-in” to receive electronic promotional communications by selecting the option to receive promotional email from us on our website. Each time you receive a promotional email, you will be provided the choice to “opt-out” of future emails by following the instructions provided in the email or you can “opt-out” at any time by following the instruction provided Cookies Our website utilizes “cookie” technology. “Cookies” are encrypted strings of text that a website stores on a user’s computer. Our website uses cookies throughout the online process to keep together information entered on multiple pages. For example, cookies enable our website to “remember” information provided to us. In addition, cookies are used to: 1. Measure usage of various pages on our website to help us make our information more pertinent to your

needs and easy for you to access; and, 2. Provide functionality such as online appointing, bill paying and other functionality that we believe would

be of interest and value to you. The two types of cookies that we use are referred to as “session” cookies and “persistent” cookies. Session cookies are temporary and are automatically deleted once you leave our website. Persistent cookies remain on your computer hard drive until you delete them. We do not use cookies to gather any personally identifiable information about you apart from what you voluntarily provide us in your dealings with us. Our cookies do not corrupt or damage your computer, programs or computer files. You may set your browser to block cookies. Fund Raising: We will not use your health information for fund raising activities without your written consent.

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 voicemail messages, postcards, or letters).

Risk Management 2013

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. We may charge a fee for producing dental records and x rays as allowed by law.

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). When you pay in full outside of your insurance plan for services you may

request that we restrict this information and not disclose it to your healthcare plan or insurer. Breach Notification: We will provide you with notification of a breach of unsecured PHI as required by law.

Alternative Communication: You have the right to request that we communicate with you about your health

information by alternative means or to alternative locations. This request must be 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. This 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 received this notice on our Web site or by electronic mail (e-mail), you are also entitled

to receive this notice in written form.

Questions and Concerns

If you would like additional information about our privacy practices or have questions, Aspen Dental’s HIPAA

Compliance Officer may be reached at 800-996-6470 extension 1250.

If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made

about access to your health information or our handling of your 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 send your concerns to Aspen Dental, Attn: HIPAA Compliance Officer 281

Sanders Creek Parkway East Syracuse, NY 13057. You also may submit written concerns to the U.S.

Department of Health and Human Services. We will provide you with the address to the U.S. Department of

Health and Human Services upon request.

We support your right to maintain 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.