TIIilOTHY J. BOIttAl'|, DDS

We ara pleased to welcome you to our practhe. Please take a few minutes tq fill qut thisform as completely as you can. lf you have any questiong we'll be glad to help you.

We looh foruard to uorking with you in maintaining your periodontal health.

PATIENT INFORMATI.ON

Home Phone ( Cell Phone {Date -Name

Lait tlerflo Fir8t tlamo

Patient EmployerlschoolEmployer/School Address

Whom msyr've thank for refering you?ln case of emergency wfro should be notified?

PRTMARY TNSUnANCSSubscriber

Le$t l{ame Fi$l }lsm! Middlg lnilt.l

Birth Date-Address (if different from Ftienfs)

Phonc I

s$# / lD#

Zip-PhoneOccuoation

Middlc lnitBl

I Prefer to be called $S#AddressCity, StateSex: MFAoeBirth

E-mail

Married Widawed$eparatad DivoroedOrcuoatlonEmployer/School Phone_

Minor*ztp-Single

City StateEmployed ByBusinesr Address Businegg Phonelnsurance Company Neme PhoneClaim Mailing

Group #

sEcoNpARY INSI,RANC-ESubscriber ss# l tffi

Lest ilarae First ilame Middli lrit8l

Birth Date-Address {if different from patienfs}State

Emptoyed By occupauon-Business Address Business Phonelnsurance Company Name PhoneClaim Mailing Address

City ?ip_ Fhone ( )

0ccupation

Group#AUTHORIZATIONI certify firat l. andlor my dependent(s) have insurance coverage with and assigndirectly to Dr. Timofry Boman all insurance benefih, if any, ethentise Bayable to me for servics rendered. I

unde*tand that I am financially rerponsible for all chargee whether or not paid by insurence. I authorize theuse of my signature on all insurance submisgions.

The abore-named dentast may u$e my lealth care information and mayditclose such iniormation to theabove-named lnrurance Company(ies) and their agents for the purpose of obtaining paymortts for services and

determining insurance benefits on the beneftts payable for related services.

Signature of Paliant, Par$tt, Guardtan qr PoGonrl Reprg8antativE tlste

ruEe F,int n.rneot Fitirlni prrcnt Guariian s Psrcooat BEPrtmnE$/e Drb

Payment is due in full at time of treafnent unleeg prkrr arrangements have been made.

.Over-

MEglcrlll{llirgRY

Physician NamqFtcrra circb pu.an3ulEf8i or en:$vff ln thg sprca frEvi&.|.Yes Ns 1. Are ygu undar the care of a physician norrr/? lf gs, for what reason:

Phene (

Yas No 2. Are you taking Eny rnedicetions? lf so, please list

3.F}ease1istthemedicalconditionsrequiringthesemedications:

4" Are you allergic to: Penicillin0r any qther medicatiens; lf ss,

Tetracycline LoellnjectedAnesffretics Latax Csdieneplease list:

YrgVarYisYarY6sYtsYasYseYasYarYrsYlsYeeYGsY6sYcgYe$YoB

YcsYssYsgYceYasYe$YcaYcsYcaYcsYosYG3YasYasYosYrsYrsYsc

YcEYegYssYceYttYsgYosYor

YcgYaaYesYceYorYasYcgYcgYesYB$

Ho AIBS/tllVNs AnemiaNo Arthritic, Bhaumstl*mNo Afiffici8l Hsart VelvesNs ArtificislJointsNo A$hmaNo tseclc PrebbmNo Bbading abnomolly wilh

rxtrac{lons or surgaryl.lo tslcod DiccassNs CanccrHo ChsmicelSapcndencyNa ChrmothcrspyNo ClrculrlEry FrchhmpNo Conganitel l.lcrrt LcsionrNo CsrtironaTrcltmenlsNo Cough, panislsnt or blpodyNo EiabctpeNo Ds you wenrcontaLi |tnsag

No EpilepryNo Feinting or DizayneesHo GlauosmeNo Haed.cicstlo Heert MurmurNo He.rt ProbhmsNo Hepatitis Typc _No HorpoeNo High Blood PrcssurcNo JrundicaNo Jew PrinHo Kidnoy DbcasaNa Livcr OlsGr$eNs Lew Bleod FrsesurgNo Mitral Valva ProlapscNo i.lsrvous PrpbLmsNe PaemakerNo Fsychietric Care

Ns Rrdiation TreatrnsntNo RasBiratery EireaaeNo Rhsumalic FsycrNg Scarlst Favcrt'lo Shortrsss of BrcalhNo Sinus TrsubleNo Skin RaahNo SPociqliliatNo StrokaNo $wollsn Filt orAnl(bsNo $wollan Nask GlrndsNo Thyroid PmblemsNo TsnsillitiENo TubcrculosicNo Tumorergrgntb on hgad orncEkNo Ul*rNo Vancrcal Ois€aisNo Weigtrt Loee, unaxpleincd

Womrn: Yce NsYaa No

Arc you prrgnant? 9uc dateTaking Birth Conlrol Pille?

Yes No Are you nilrsing?

pTNTAL..HISTORY

Who ie yeur general Dontist?Hew long havo yeu He€n with yeurcurr€nt general dentist?When was your laet visit?, What was done et that time?

Reason for your refenal to eur oftice

YesYesYesYesYasYesYesYes

YesYesYesYeEYeEYeE

Yee

1.2.3.4.5.6.7.L

NoNoNoNoNoNoNoNo

Are you having dental pein at this time?Heve you ngtic€d any lessening of yourteeth?Do you sufer from painlor swelling af your gums?Be your gums ble€d while cleaning yorrr teeth?Are yeur teeth sensitive to het, celd or sweets?Have yeu ewr had oral surgery?l-{ave you ever had orthedontic treatrnent? {braces)Have you ever had poriedentaltreatment? {gum treatment. lf yes, when and whet type?

NoNoNoNoNoNo

No

9. Have ysu ev€r work a bite plate 6r @ther appliance?10, Have ycu ever had difficulty in opening er clasing?11. Have yeu evar had difflculty in chewing?12. Bo )/ou clench or grind your teeft while ewake er asleep?13. tr)o you mouth breathe while awake or asleep?14. Oo yeu censume tobacco products. lf yes, which preduc,ts and how much per day?,

15, Bs yeu feel ntsrvoua ebout having dontel treatment? Whet ean we do ts maka yeu fuel morecomfortable?

$ignature of Fatient (Or Parent if a Minor) Dato Reviewed tsy

NHOTHY J. BOHAf{, B,D.S.

ASKHOUTfLEDGENilEHT OF RECHPT OFl,tOTlCE OF PRIVACY PRACTICES

nYou t{ry Hcfnst tc $ign This Adrnowl@emonP

I, have rweived a mFy ef this ofEcg$Notice ofPrtwcy Frec{*s,

tPlease Prir* Name!

{Signatura}

{Datsi

Fsr0ffiee tlsr Oaly

lAIe attempted to obtain written acknorrledgement of eceipt of our Notie of PniusyPraftiors, but acknowledgnrnent coukl not be obtrined berluse:

lndMdual refi,lesd b srgn

' .*,kn-#.fr':mf ists bsriers profiiblted ohteinlng the

r An emcrgonry sitmtion pmvented us from cbtainingacknowledgeraenl

Oths (PleaEe Specify)

O 20EO Araaroen Os6d Aia6i.tim

Timothy J. Boman, D.D.S.

Periodontics and Dental Implants 25460 Medical Center Drive

Ste #204 Murrieta, Ca 92562

951-677-7785

We want to thank you for giving us the opportunity to serve you. You are the most important part of our practice, and our primary goal is to provide you with the very best oral health care. We are proud of the fact that we use current techniques and our sterilization methods are of the highest standards. We understand that you may have questions regarding your financial obligations, and we want to make certain that you have a complete understanding of our financial procedures and practices. Please review the following: 1. INSURED PATIENTS: We are pleased that you have dental insurance! Please note that not all services are covered benefits in all contracts. YOU are ultimately responsible for all fees incurred for services rendered to you. We do not write your dental insurance contract or policy. This is an agreement between your employer and the insurance company. We will do our very best to see that you get the maximum benefit allowable. ALL CO-INSURANCE PAYMENTS ARE EXPECTED TO BE PAID AT THE TIME SERVICE IS RENDERED. Without an insurance predetermination (except for Delta of California) you will be billed as a cash or non-insured patient. 2. NON-INSURED PATIENTS: Payment is expected at the time service is rendered. 3. APPOINTMENTS: When an appointment has been made, this time has been reserved especially for you. If you are unable to keep your scheduled appointment, kindly give 24 hour notice. We charge a $60.00 cancellation fee without a 24 hour notice. While we try to give a confirmation phone call for most appointments as a courtesy, keeping your appointment is ultimately your responsibility. Thank you for allowing us to serve you. If you have any questions, please feel free to ask us. Sincerely, Timothy J. Boman, D.D.S. and Staff _______________________________________ Patient Signature _______________________________________ Date