Richard H. Lazor, D.D.S.

MEDICAL HISTORY

PATIENT NAME Birth Date _

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you mayhave, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

I following questions.

Are you under a physician's care now? 0 Yes 0 NoHave you ever been hospitalized or had a major operation? 0 Yes 0 No

Have you ever had a serious head or neck injury? 0 Yes 0 NoAre you taking any medications, pills, or drugs? 0 Yes 0 No

Do you take, or have you taken, Phen-Fen or Redux? 0 Yes 0 NoAre you on a special diet? 0 Yes 0 No

Do you use tobacco? 0 Yes 0 NoDo you use controlled substances? 0 Yes 0 No

L!r~:::tIT~:;~o ~~~~gnant? 0-~-ON; '~~~~~~~p;ives;O' yes.9 No =- Nursing? -0~~~~--~_~~-~~][-Are you allergic to any of the following? .-- ~-----~--'--- --- ---. -.

I D Aspirin D Penicillin D Codeine D Acrylic D Metal D Latex D Local Anesthetics J'I D Other If yes, please explain: _

.-_._._----- _. ------ - .---. - -- ~

If yes, please explain: _

If yes, please explain: _If yes, please explain: _If yes, please explain: _

r-DO you have, or have you had, any of the following?

I'AIDS/HIV Positive 0 Yes0 No Cortisone Medicine 0 Yes0 No Hemophilia 0 Yes0 No, Alzheimer's Disease 0 Yes0 No Diabetes 0 Yes0 No HepatitisA 0 Yes0 No, Anaphylaxis 0 YesO No Drug Addiction 0 Yes0 No Hepatitis BorC 0 Yes0 NoI Anemia 0 Yes0 No Easily Winded 0 Yes0 No Herpes 0 Yes0 No

Angina 0 Yes0 No Emphysema 0 Yes0 No High Blood Pressure 0 Yes0 NoI Arthritis/Gout 0 Yes0 No Epilepsy or Seizures 0 Yes0 No Hives or Rash 0 Yes0 NoI Artificial Heart Valve 0 Yes0 No Excessive Bleeding 0 Yes0 No Hypoglycemia 0 Yes0 No

Artificial Joint 0 Yes () No Excessive Thirst 0 Yes0 No Irregular Heartbeat 0 Yes0 NoAsthma 0 Yes0 No Fainting Spells/Dizziness0 Yes0 No Kidney Problems 0 Yes0 NoBlood Disease 0 Yes0 No Frequent Cough 0 Yes0 No Leukemia 0 Yes0 NoBlood Transfusion 0 Yes0 No Frequent Diarrhea 0 Yes0 No Liver Disease 0 Yes0 NoBreathing Problem 0 Yes0 No Frequent Headaches 0 Yes0 No Low Blood Pressure 0 Yes0 NoBruise Easily 0 Yes0 No Genital Herpes 0 Yes0 No Lung Disease 0 Yes0 NoCancer 0 Yes0 No Glaucoma 0 Yes0 No Mitral Valve Prolapse0 Yes0 NoChemotherapy 0 Yes0 No Hay Fever 0 Yes0 No Pain in Jaw Joints 0 Yes0 NoChest Pains 0 Yes0 No Heart Attack/Failure 0 Yes0 No Parathyroid Disease 0 Yes0 NoCold Sores/Fever Blisters0 Yes0 No Heart Murmur 0 Yes0 No Psychiatric Care 0 Yes0 No

I Congenital Heart DisorderO Yes0 No Heart Pace Maker 0 Yes0 No Radiation TreatmentsO Yes0 NoIConvulsions 0 Yes0 No Heart Trouble/Disease 0 Yes0 No Recent Weight Loss 0 Yes0 No

I._ Have you ever had any serious illness not listed above? 0 Yes 0 No If yes, please explain: __-=--_-_--_-==--=--_-~~=-----------

Renal Dialysis 0 Yes0 NoRheumatic Fever 0 Yes0 NoRheumatism 0 Yes0 NoScarlet Fever 0 Yes0 NoShingles 0 Yes 0 NoSickle Cell Disease 0 Yes0 No ISinus Trouble 0 Yes0 No !Spina BiMa 0 Yes 0 NoStomachllntestinal Disease 0 Yes0 NoStroke 0 Yes0 NoSwelling of Limbs 0 Yes 0 NoThyroid Disease 0 Yes 0 No ITonsillitis 0 Yes0 No ITuberculosis 0 Yes0 No 'Tumors or Growths 0 Yes 0 NoUlcers 0 Yes 0 No IVenereal Disease 0 Yes0 No iYellOWJaundice 0 Yes0 No

Comments:

SIGNATURE OF PATIENT, PARENT, or GUARDIAN ~ DATE _

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

PATIENT REGISTRATION

10: _ Chart 10: _

First Name: _

Patient Is: 0 Policy Holder

o Responsible PartyResponsible Party 0fsomeone other than the patien0-----------------------------------------------------------------~

First Name: Last Name: _

Last Name: Middle Initial:

Preferred Name: _

Middle Initial:

Address: Address 2: _

City, State, Zip: Pager: _

Home Phone: Work Phone: Ext: Cellular: _

Soc Sec:Birth Date: Drivers Lic: _

o Responsible Party is also a Policy Holder for Patient

Patient Information----------------------

Address: _

o Primary Insurance Policy Holder 0 Secondary Insurance Policy HolderL- _

Address 2:

City: State I Zip: _ __ Pager: _

Home Phone: __________________ Work Phone: _ Ext: Cellular: _

o SingleMarital Status: 0 Married c) Divorced 0 Separated 0 WidowedSex: 0 Male

Birth Date:

o Female

Age: _ Soc. Sec: _ Drivers Lic: ---------------------E-mail: _ o I would like to receive correspondences via e-rnail.

Section 3Section 2

Employment Status: 0 Full Time

Student Status: 0 Full Time

o RetiredCell#: --------------

Emergency #: _

FaX#: ---------------Pager#: _

o Part Time

o Part Time

Medicaid 10: Pref. Dentist: _

Employer 10: Pref. Pharmacy:. _

Carrier 10: Pref. Hyg.:

Primary Insurance Information

Name of Insured: Relationship to Insured:O Self o Spouse 0 Child o Other

Insured Soc. Sec: Insured Birth Date:

Employer: Ins. Company:

Address: Address:

Address 2: Address 2:

City,State,Zip: City.State.Zip:

Rem. Benefits: .00 Rem. Deduct: .00

Secondary Insurance Information

Name of Insured: Relationship to InsuredO Self o Spouse 0 Child o Other

Insured Soc. Sec: Insured Birth Date:

Employer: Ins. Company:

Address: Address:

Address 2: Address 2:

CitY,State,Zip: CitY,State,Zip:

Rem. Benefits: .00 Rem. Deduct: .00

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability and Accountability Act of 1996("HIPAA"), I have certain rights to privacy regarding my protected health information.I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiplehealthcare providers who may be involved in that treatment directly andindirectly.

• Obtain payment from third-party payers.Conduct normal healthcare operations such as quality assessments andphysician certifications.

I have received, read, and understand your Notice of Privacy Practices containing amore complete description of the uses and disclosures of my health information. Iunderstand that this organization has the right to change its Notice of Privacy Practicesfrom time to time and that I may contact this organization at any time at the addressabove to obtain a current copy of Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information isused or disclosed to carry out treatment, payment, or health care operations. I alsounderstand you are not required to agree to my requested restrictions, but if you do agreethen you are bound to abide by such restrictions.

Patient Name ---------------------------------------------------Relationship to Patient: _

Signature: ~ _

Date: ---------------------------------------------------------

OFFICE USE ONLYI attempted to obtain the patient's signature in acknowledgement on this Notice ofPrivacy Practices Acknowledgement, but was unable to do so as documentedbelow.Date: Initials: Reason:

WELCOME TO OUR PRACTICE

Richard H. Lazor D.O. S.

We are committed to providing you with the best possible care, and we arepleased to discuss professional fees with you at any time. Your clear understanding ofour office policies is important to our relationship. Please fell free to ask any questionsregarding fees or treatment.

. All patients must complete our "Patient Information" forms prior to seeing the doctor.

. An adult must accompany minors: the adult accompanying a minor is responsiblefor payment in full at the time of service.

FINANCIAL POLICY; Payment in full is required at the time of service. We acceptmost credit cards, cash or checks (local). Please free to discuss payment arrangementswith our business office. In the unfortunate event that this account becomes delinquent,any additional fee or charges incurred to collect this debt will be passed on to thisaccount.

REGARDING INSURANCE; Insurance is a contract between you and your Insurancecompany. We are not a party to this contract, or responsible for your Insurance notpaying. We file Insurance claims as a courtesy to our patients. We will not becomeinvolved in disputes between you and your Insurance company regarding deductibles,co-payments, covered charges, secondary Insurance, "usual & customary", or etc. otherthan to supply you factual information as necessary. You are responsible for the timelypayment of you account.

MISSED APPOINTMENTS; Our policy is to confirm your visit at least 24 hours inadvance. Cancellations with less than 24 hours notice make the office incur unnecessarybusiness expenses. Appointments are specially reserved for you. This short period oftime does not allow us to refill the open appointment time and interferes with otherpatients needing our services.

TRANSFER OF RECORDS; In the event that your records or x-rays may need to beTransferred there will be a fee to cover duplications and administrative costs (up to$25.00).*ALL ORIGINALS MUST REMAIN IN THE OFFICE

Thank you for reading and understanding our policy. Please let us know if you have anyquestions or concerns.

Signature Date _