Scott Harris, D.M.D., P.A. - Patient Medical History Page 1 of 3

Harris DentistryScott Harris DMD : Daniel Gewartowski DDS

● Personal Care Dentistry ●2600 North Military Trail, Suite #348, Boca Raton, Florida

33431 (561) 241-7272 office ∙ (561) 241-4986 fax

Welcome to our office! We are looking forward to you joining our dental family of friends. It is our goal to help you achieve both ideal dental health and the impeccable smile you want and deserve. Please complete this form so that we may provide you with the best possible care. Thank you!

Date: _______________ Whom may we thank for referring you to our office? _______________

Personal Information

Dr. Mr. Mrs. Ms. Miss Patient’s Full Name Suffix: Sr. Jr. III IV

Sex Age Date of Birth

Home Street Address Apartment #

City State Zip Code

Home Phone # Home Fax # Pager/Cell Phone #

Employment Information

Occupation Employer Name

Work Street Address Suite #

City State Zip Code

Work Phone # Work Fax # Pager/Cell Phone #

Other Information

E-mail Address: ______________________________________________________________________

When is the best time to contact you? At which phone # ?

Marital Status: ( )Single ( )Married ( )Divorced ( )Widowed Spouse’s Name:__________________

In case of emergency:

Contact Name Relationship Phone #

Scott Harris, D.M.D., P.A. - Patient Medical History Page 2 of 3

Medical History

Primary Care Physician Name City State Office Phone #

Date of Last Medical Exam: ____________________

How would you rate your current state of medical health? ( ) Excellent ( ) Good ( ) Fair ( ) Poor

Do you smoke or use smokeless tobacco? ( ) Yes ( ) No If yes, how often? ____________________

Are you currently taking any prescription or non-prescription medications? ( ) Yes ( ) No

If yes, please list (or provide a list) the name, dosage, and purpose of each medication:

Medication Name Dosage Purpose ________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Do you have, have you had, or have you ever been treated for any of the following medical conditions?

Yes No Heart Attack/Stroke Yes No Heart Murmur/Rheumatic Fever Yes No Hepatitis/Jaundice Yes No High/Low Blood Pressure Yes No Epilepsy/Seizures/Fainting Yes No Abnormal Bleeding Yes No Cancer/Chemotherapy Yes No Kidney Disorders Yes No Psychiatric Disorders Yes No Type I Diabetes/Type II Diabetes Yes No Tuberculosis/Pneumonia Yes No Drug/Alcohol Abuse Yes No Anemia Yes No HIV/AIDS

If you have ever been treated for any other medical condition/illness not listed above, please explain:

If you have ever had surgery of any kind, please explain:

If you have been diagnosed/treated for any medical condition within the last 5 years, please explain:

Do you need to be pre-treated with antibiotics prior to dental treatment? ( ) Yes ( ) No

Are you allergic to any of the following medications?

Yes No Penicillin Yes No Aspirin Yes No Sulfa Drugs Yes No Erythromycin Yes No Codeine Yes No Local Anesthetic

If you are allergic to any other medications, please explain:

Scott Harris, D.M.D., P.A. - Patient Medical History Page 3 of 3

FEMALE PATIENTS ONLY:

Are you pregnant? ( ) Yes ( ) No If yes, how many months? ______________

Are you planning to get pregnant? ( ) Yes ( ) No If yes, when? ______________

Dental History

Why have you come to see Dr. Harris today? _______________________________________________

Many patients consult us for a second opinion. Is this true in your case? ( ) Yes ( ) No If yes, please explain below:

How would you describe the condition of your teeth and gums? ( ) Excellent ( ) Good ( ) Fair ( ) Poor

When was the date of your last dental visit? _________________________

What was the name of your previous dentist? _________________________

Are you currently experiencing and pain/discomfort with your teeth and gums? ( ) Yes ( ) No If yes, please explain below:

If you could wave a magic wand and change anything about your smile what would you like to do?

How often do you brush your teeth? _______________ How often do you floss? _______________

Do you use a mouth rinse? Yes No Do your gums bleed when you brush or floss your teeth? Yes No Would you be interested in safely bleaching your teeth? Yes No Do you grind/clench your teeth? Yes No Don’t Know Have you ever experienced pain in your jaw joints? Yes No Have you ever been treated for TMJ symptoms? Yes No If yes please explain below:

The information that I have provided to Dr. Harris is correct to the best of my knowledge. I understand that any and all information will be held in the strictest of confidence and used only to improve professional communications between other doctors, their staff, and myself. I also give my permission to Dr. Harris, and his staff to professionally utilize any necessary photographs taken in conjunction with my treatment.

Patient’s (Legal Guardian) Signature Date

Dentist’s Signature Date

Harris Dentistry ● Personal Care Dentistry ●

SCOTT HARRIS, D.M.D., P.A. • PERSONAL CARE DENTISTRY

2600 North Military Trail, Suite

#348, Boca Raton, Florida 33431 (561) 241-7272 office ∙ (561) 241-4986 fax

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGE FORM

I, the undersigned, have received a copy to read of Scott Harris, D.M.D., P.A.’s Notice of Privacy Practices.

Patient’s Name

Patient’s (Legal Guardian) Signature Date

Noncn or Pruvacy pnacrrcnstr you lrAvE ANy euEsfioNs Atsorrr lgts Norcr pu6AsE coNTAcr: oun px.rvgcy coMrAcr

Scott Harris" DMS, PATIIIS !{OTIC& DESCRIBES HOW DENTAI./MEDICAI Ir.'rrOirmArIon AsoUT Yo{I

MAY BE USED AND DISCLOSED AND HOW VOU CAN GBT ACCESS TO THIS- IN}"OTMATION.

l'hlr Nofire of Prlvacy Pracfices ttcscrlbcs how $e may u,rc anrt dtsrlosc lnur protected hertth Infornrrdon to cgrry outtrcshEtlt' PAy[lcnt or hrallh catc op*ratlonr and for othcr pnqroses Urrt rre ptrmt*+a or rtsqutrod by taw.

lY-e arc re4ulred lo ablde by lle termr ofthls Noflce oflrlvecy Practlccs. lYe nray ehange thc te.rms of our no(cc, at any itmc.

Thenennodce Eill be effecttve for all pr*tectat heallh trformr8onthatwe m.Nlninln at;hlttrma

UST'.$AND DISCT,OSUITESOTTRO?EC'TBDITEALTT{ INF'ORMATION IIA$OD T'PONYOURIVRTTT&N CONSEN'IY. on.witl be asliod by your dentist (o sign a ccnsent/adcnowledgnmt form. By signingthc ccnsavadtnowtetlgrr*i f'"*, i*,

-- -

dsltis, our offilr, $aff and others orrtside of our offoc 0rat arc involved in your oare irrd rreatnrslt for &o prulrxc of pr*iaing tr""l.hcore rytrorylo Ylu may also use and discloseyorr PltI (prot{ded healfi iirfornation) to pay yourheaftt cari bills aridto eupiort rloqrention oflhe dar{id's office.Follorvi:rg aro exrrplcs uflhetypes ofuses and d.isclosures of)'ourprotsc{gl health erre infonuation ilratthe dentitts offrw ispernitled to mako cror you have *ignod our conserrtlad<nowledgrnurt fcnrn.

Trert lteritl Wewill uso alrd dbcloseyourt)rote€t€d health inlbrnrafion toprovirtq qoordin{tq or ntauage your datal care and anyrclalcd scrvice*. This irrcludes lhecoordination orma.nagcnrat ofyourdettal carervith a thirdpartythoihas olreatly otrailed youipornission 1o hoYe rrccess 10 your pNteded heatth inforrnstiod.

PstrT nentl Yortr proledrd dtntal infomralion will be usal rs needed, to ohain paymcnt for your dartal eervices. This noy irclude<xrtain acdivitirxlhal your drrlal insurencefilan may rndutakobcfore itappmverorpals forthe O,rrral caroservices ryctpcoruntsrdfo'r you.zudr as; nraking a dder:nination ofeligibility or oovaagofor ianriarcs berr#r&, reviewirrg *cviox providuJ to you formedi<al ncccesity, afidurtdat king utilizrtion rwierr adivities.

Healtlrc*ra Ope rn{lonr: we may use or discloec, asoeeded, your prote*ed bcath ilformation in ordsr to sq)paa rhe busincssartivities ofyour darli$'s pradie. These adivities include, but arenol linritodto, quatily assessmenl rdivities, urrployooreviewtdivities' lrabrfurg of medical srrldeirts, liwrsing narketing and lindraising adivitiec, ard artduding or anmging'foiothu busincssactivities.

In addilier, wemey usr: a sip.in s,l.red atlhe rogidralion dek rvhere 1,ou r*ill bo askedto sign your nomo and indicato yorrd&ttist,

-We_may atso call you by narue h tllc rvaiting room *,heu your dcrlirtis re*dyto rue you. Wi *uy u.e or discloce your prore*ed

health infonnation, as necsary, to cord6ct you to rernind you of your appointnrett. ^

Wervill $arolour protedcdheallh informatimvrith thid pady tbrrsirrew asrcciatee" lhatpolbrrn various activities (og, billiug"hanscriplion serviccs) ttrthcpradim. Wborwer an anatgana{ bcween our ofroe and abusisxs assoeiate involue"tti*,,s" oidisclozure ofyourprotoddhealth in&rnraticn, warvill have a rrifi.qr contract.ftrr ccntains trmu thar will pmtectihcprivacy of yourproteclod hEalth infomstion,

\tc may rtseor disclose yourpro{cdcdheafth infermalisr, as necfssary, topr*virleyou rvith infonnaticn about lr€atnrent alt{rnalive$ot o{hq heahlt.reldod bcrte{its and scrvices that nr6y be of interesto you. Wo nay also use and discloce your prctectct hxlthinfomaliqr.for other markding ac{ivitix, For exnnplo, your nome and addre$ maybo tsorlto seid you a newsle{rr 6bolt1 o[rptactic€ aod tltc sewi<w rve olfe. 1Ve may also smd yorr infbnnalion aborr produds or sef,vioes rhat we ficliove nray bc baeficial royou. You may contad our hivacy Contact to rquest th{tlhcse mnleriats nQt bs sqlt to you.

Other utcs aad disclogures ofyourprolodedheahb inlaruralim will bemade urly with your writor au0orir*tion, rmlcss dherwisepennitted or reguired by law as describod below. You oray revokethis *uthorizatiur, at any limg in lrniling excqt lo lho assot lfiatyour do{h0 or tltc d{nti{'6 pradics tos taken an action in rolionce on lftp uce or disclosure irrdicated in theiuhorization,

Other fcrrnit&d and Reqdred Uses and Dlsclosur$ Tiat llfry Be Medc YYI& Your Consent, Authorlzatlon or Opporturltyto Objfct

We nny use and discloso yolr prcteded health infomutiur in lbe followitg in:1soes. You havo tlro oppodunity to agrer or obje<r to&e use or distlosure of all or part of your proterted health infoftration. If you cru nd prescnt or able to agrw or objed to theuse ordisclooure ofthopr<rlededheatth irfonnation, thrn your do*i.rt moy, usingprolixsic,nal jutlgrnert, dCennilsqtrA[sr$e djsolosurc isin your best intcest lnttis cue, onlythe protedexl health infcmrati.on thai ic relevsnt to yoir hea[h car$will bc diselsrod.

otherc Invulvc<l ln Your lleallhcare: IJnle*s you objoc! we may disclosalo a nrenbtr ofyour fanily, a relrtivq a closp frimd oraly o{herpersan you id*lifu. your proteded health infonnatian lhat diredly relalcs to that person's involvorrcnt in your rft:rtal care,

Ifyou arcrnablo to agree or objoct to suc*r a dirclosurg tvc may disclose sudr infotmatiql a$ neo{$$ary ifwe d*etnirre that it is inyour bd intcrsd based otr our proflseiorral judgrnrrt. We may uso or disclose prc{eciat heafi}r information to noti} or o\rist innotirying a f6mily mmbct, pc:oarl rcpresantativo or any other perscn that is respoosiblo for your care of your tocatim, gencralconditita ardcath. Finolty, we may use ordisclose yourpro{€dcd health irformaii.rr to an auihorizrd pubiic orprivatedtityro assisrin disader teliefetroris and to coordiaale uses and discloiu.r$ to family or crlber individual.e involved in your heatlh cnre.

F-mergencle: Wornay ux ordisclosoyourprotededhealth infonnatim in arr en€rEureytrrxtrnort sihaior. Iftlrishappe*s, yourdeotist dlrl| try to o&ain lour cursat as soon as reasodably praciiceblo alier the delirei oflredmcat, Ifyorrr denti$ o; mod,;dartist in lhe pndico is required by law to tr€at you, and rho deoli.* has dt€fiptQd to oHain ).our ccngca!-brl is unabte to obtain 1,ourccnss{ he or $re nray Sill rxo or dlsclose your prcrtxted heafth in&nnatim to ueot 1ou.

Conurudcldon llrrrleru: lVe nay usc md disclosc your protedctl health informrtion if yoru dsrtig or andher denlis in thopln(li(}g afl$lpts 1o obtairt consent fiom you but is uleblsto do so duc 10 g0bstnntial (silmil$ication barri€r$ a'|d dl6 diillisddenrthesr ushlg profesricrrd judgnent, that y'ou int$d to cmsedt to uro or disqlosrrc un<ter lhs circirnr.gan<xrs,

Wc m4y r!'F or dl*g!9!gv.!Erf nlot+cted hsl.ttr lnformatlo[.ln lhc to,tlgrvlJ:s sltgrtipus]r!hoJr,t-y,ogf$;pn$entorpqtiorlzsdoni

1ltcn reqnlrtd Sy Larv' ftr}llc llealllq Conununlcable llkeues, elttr Overutght, Atusc or Neglect, Food and DrugAdmtatstratiott, I*gal Prccccdlngs, Low Enfor*enrent nCoronere, Funeral Dlmcto$, and Organ Donation, Crlraind Actlvtty,MlXt$'' Acthilty, Imntto aod Nntlonal gecur{ty:

Requlred Usec and Dlsclosur€$: Iftdmthelaw,we mu$ makadisclosurestoyou andrvfi* rquired byihe Secrdngy oftheDt1pfit nent of ll{:alth snd Humr$ $ervices 1o inve(igale or ddermine our conqrliance.

l'ou hxve lhe rlght to fuispest snd coly Jour protectid henlth hforrnafion

You bave tho riglrt to regues a recricticr ofyour prd€{t€d health informatiqr, This means ycu may ask ur not to uso or discloso anypad of)'oilrprotsded heaLh inlbrmation for lhepurposcs oflrcotrno{ px),rncnt or heatthcare qpatdons. You may also rcquesifratany p$rt of your protcded health information not bs dirclooed lo family mtnrbers or fiorrls rvho may bo invoh,ed in your care or tbrno{i{ication purlosct as d{Gsibed in $it No{co of hivaoa ltadiqes. Your requed must $:tethe spccifiore$riction reqrestod indlowhom you wrnt thc msrricticat to apply.Your dsrtig is nd r&Iuirtd to agtee to a r'esirictiqr that ygu r€que$, Ifdentirt belisr'€$ it is in your bed intocst 1o prnrh use anddisclosure ofyourpro${redhcetfl inforrutisr, yourprolected heahh informrtjon willnot be resdded. fyour d$1iS does agrer tothe reque$ed regridiur, rvc may not use or disclose your proteued heafrh informalicn in viol*ion ofthal rtx{rittion rmtess it isneededto provide sncrgency trcdnrent

You havelhe rigltt to rcquesttor€o€ivo cortfidfftial corilmuricatiEnsfronr u$ by ahernu{iv'c mewrs o.at an oltemative location. lVenill amommodrle reasocatle requess. We may also cmditioo this acqmrrodation by askirrg you fsr infofirttior as to how paynrartwill behandled or ryecificarior of an aheroalivoad&css or other method of contad, Worvilt not r€$red an explaratiear from you as lol$e basis for{ronques( Plessemakotlris roquest ia lvdringto our ltivacy Coatad.You may harr lhe riglr! to luvo I'olr d*rti* anrerd your prote{ied hsalh informatioo. T'his means you ur{y nrqu{$ o$ Bmcrr&rort ofprcfecloJ heal0r information atout you in a designated rcoord sst for as l(ag rs wo ruaintain tlig irfonnation. h oatais cas€$, we msydany your rcqued for nn anteadmsrt. Ifrre deny your mqucg for snrordtrrmt, you havclto right 1o file a slslsnEnt oltlisagreanortwith us ard wc nray prqare a rdrrltal lc your SalffiKnt and rvitl provide you rviti a crpy of sly zudr rsbt(tal.

You havcthe rigltl to receive an accoroling ofcertain disclosures wo havc mrdc, ifany, ofyour prc{ocretl hcalth information. 'lbisridbt sttpli€s to diselosures for purpooes e$ter than {reitmerf, payment or healthcarr opdrati(a$ ss de*cribed io this Notirx of PrivacyPradicxs.

You havethe riglrtto ohain apaper ctpy of0risnodice from rn, upoo reques, even ifyou hava sgrsodto acoqrttbis noticoclarrurically.

Co$plalsls

You nnay conplaintotls slolhe Sesrlart of Healh anal Human Services ifyou beliore your privacy riglrts har.e bwr violated ty us.You may filc a culplaint with us bynotifyiug ourprivacy cotrlact of your conploinl" Wo will no{ rd'rliate agains you for filing aconplaint.

fiII,$ NorIcIt WAs YUBLI5IIED AJYD Dr:corrEs trFF.E(:T I. ON/on ArTbtr Ju|-RIr,fjJ@

Page 1 of 2

Office Policies

Thank you for choosing us as your dental health care provider. We believe that all

patients deserve the very best dental care we can provide. We also believe that everyone

benefits when specific financial arrangements are agreed upon. Please understand that

payment of your bill is considered a part of your treatment. The following is a statement

of our Office Policy which we require that you read and sign prior to any treatment. All

patients must complete our information and insurance forms before seeing the doctor.

FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS,

VISA, MASTERCARD, DISCOVER AND AMERICAN EXPRESS CREDIT CARDS,

AND DEBIT CARDS. WE ALSO OFFER CARE CREDIT WHICH IS AN

EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL.

Regarding Insurance

We request that any co-payments, deductibles, and any services not covered by your

insurance plan be paid at the time the service is provided. The balance is your

responsibility whether your insurance company pays or not. We cannot bill your

insurance unless you bring in all insurance information at your initial visit. It is the

patient’s responsibility to notify the office PRIOR to your appointment of any changes in

insurance coverage. Your insurance policy is a contract between you and your insurance

company. We are not a party to that contract. If your insurance company has not paid

your account in full within 45 days, the balance will be automatically transferred to your

account. Please be aware some and possibly all of the services provided may be non-

covered services and not considered reasonable, usual, and customary under the terms of

your dental and/or medical policy.

Missed Appointments

In order to give you, and all of our patients, the best possible care, we request that you

review our policy regarding missed appointments. A missed appointment is when you

fail to show up for an allotted appointment time, without a phone call or cancellation

Page 2 of 2

notice of at least 24-hours (not including weekends, must cancel on Friday for Monday

appointments).

Please remember that we have reserved appointment times especially for you. Therefore,

we request at least a 24 hour notice in order to reschedule your appointment. This will

enable us to offer your cancelled time to other patients.

If you are unable to keep your scheduled appointment time, please call our office at least

24-hours in advance in order to avoid a missed appointment fee. Your phone call is

critical in helping us provide continuous care to all of our valued patients. If you fail to

give us notice of your missed appointment, you will be charged a $95 missed

appointment fee. This charge is not covered by insurance. If you fail to give proper

notice you may be subject to a deposit for future appointments.

Billing

All accounts which have not paid the estimated portion of their bill at the time of service

will incur a $3.00 billing charge each month until the balance is paid. There is also a $30

returned check fee.

Refunds

Refunds for overpayment will be sent after all treatment is completed and insurance has

been collected.

Collections

Any account that has not received payment in 60 days will be handed over to a collection

agency that will pursue the responsible party for reimbursement. This will negatively

impact your credit history and limit the treatment you can receive at our office. In

addition, any fee that is charged by the collection agency will be transferred to the

responsible party and be their sole responsibility.

Thank you for understanding our policies. Please let us know if you have any questions

or concerns. We look forward to providing the highest quality dental care in a relaxing

and caring atmosphere.

By signing below I acknowledge that I have read the above policies and understand and

agree to these policies.

Patient Name: ________________________________________________

Patient/Guardian Signature: _____________________________________

Date: ________________________________________________