New Patient Questionnaire

1.) What is the reason for your visit today?________________________________________________________________________

2.) How were you referred to us?________________________________________________________________________

3.) Have you had an unfavorable dental experience in the past? Yes NOIf yes, please explain: ____________________________________________

4.) Are you happy with your smile? Yes NOIf no, please explain: ________________________________________________

5.) Would you like whiter teeth? YES NO

6.) Are you missing teeth? YES NOIf yes, are you interested in replacing them? YES NO

7.) Are you especially anxious or nervous at the dentist? YES NO

8.) Do you clench or grind your teeth? YES NO

9.) Do you have jaw pain or discomfort? YES NO

10.) Do you have frequent headaches? YES NO

11.) Have you ever been told you have a TMJ problem or disorder? YES NO

12.) Do you snore or have you ever been diagnosed with sleep apnea? YES NO

All of the preceding answers and information is true and correct to the best of myknowledge.

Signature: ________________________________ Date: ___________

r

If yes, please explain:

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date ____________________________________

Are you under a physician's care now? Yes No If yes, please explain:Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?Have you ever taken Fosamax, Boniva, Actonel or any

other medications containing bisphosphonates?

Yes No If yes, please explain:Yes No If yes, please explain:Yes No If yes, please explain:Yes No

Are you on a special diet? Yes NoDo you use tobacco? Yes No

Do you use controlled substances? Yes NoWomen: Are youPregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No

Are you allergic to any of the following?Aspirin

Other

Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs

If yes, please explain:

Do you have, or have you had, any of the following?AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial Joint AsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisordeConvulsions

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

HemophiliaHepatitis A Hepatitis B or C HerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve Prolapse

Pain in Jaw JointsParathyroid DiseasePsychiatric Care

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes No

Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal Disease

Swelling of LimbsStroke

Thyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Have you ever had any serious illness not listed above? Yes No

Comments:

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 may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Yes No

Osteoporosis Yes No

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.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________

Financial Agreement

Responsible Party’s Name:_________________________________________________________________IMtsriFtsaL

__________________________:tneitaPotpihsnoitaleR#.ceS.coS

Address:_____________________________________________________________________________

________________:piZ:etatS:ytiC

Home #: _____________________ Work #: _________________ Cell #: _______________________

____________________________________:noitapuccO:reyolpmE

Address:_____________________________________________________________________________

City:_________________________ State:_____________ Zip:___________________

Insurance Plan Name and Address: __________________________________________________________________________________________________________________________________________________________

Insurance Plan Phone Number: ________________________________________________________

_______________________________:rebmuNDI:rebmuNpuorG

As a condition of treatment at L. Patrick Grisanti II, DDS, PA, financial arrangements must be made inadvance. Payment will be due at the time services are rendered unless other written financialarrangements have been made. Insurance claims will be filed as a courtesy, and your estimated portionwill be due at the time services are rendered. I understand that insurance estimates cannot be guaranteedand are only estimates. It is the patient or responsible party’s responsibility to understand his/herinsurance policy including, but not limited to, exclusions, limitations, maximums, waiting periods, andcovered/noncovered benefits. After all claims have been processed any unpaid portion must be paid infull by the patient or responsible party. Any credit will automatically be applied to the patient/responsibleparty’s account unless a refund is requested. A service charge of 2% per month on the unpaid balancewill be charged on all accounts exceeding 60 days, unless previously written financial arrangements havebeen made. I grant permission to you or your assignee to telephone me at home or at my work, and/orprovide correspondence by mail to discuss matters related to my account or this form. I authorizeassignment of benefits to L. Patrick Grisanti II, DDS, PA and this agreement will serve as my signatureon file.

The information on this form is accurate and I have read the above financial agreement and agree to theircontent.

________________________________________________________ ___________etaDytraPelbisnopseR/tneitaPfoerutangiS

Dental Treatment Consent Form

1.) Health Information: I agree to disclose all previous medical history, illness, conditions, and current/pastmedication. Undisclosed medical information can lead to potentially life threatening situations.

2.) Comprehensive Examination: As the standard of care for this practice, a new patient appointment will consistof the following: a current panoramic radiograph with four bitewing radiographs OR a full mouth series of x-rays;comprehensive examination; full mouth periodontal evaluation. In addition, other diagnostic tests may benecessary, including but not limited to, intra-oral and extra-oral photographs, pulp testing, additional radiographs,diagnostic casts. I authorize Dr. L. Patrick Grisanti II, DDS to perform any procedures or tests necessary to makea complete diagnosis of my dental needs.

3.) Additional or Specialty Care: I understand that I may need treatment beyond what was originally planned.Treatment plans may need to be modified at the time of treatment due to unexpected conditions or extent ofdisease progression. I agree to be financially responsible for the additional treatment or for referral to a specialist.

4.) Gum treatment: I understand that this office requires a periodontal evaluation for all new patients. At this timethe doctor will determine if a regular cleaning (prophylaxis) or deep cleaning (scaling and root planning) will benecessary. The cleaning appointment may need to be scheduled at a following appointment. Periodontal diseasecan have potential complications with overall systemic health, including diabetes, high blood pressure, pretermlow birth weight babies, heart and cardiovascular disease, and other effects on systemic health. I understand thatperiodontal disease and disease progression is negatively affected by noncompliance with reevaluation and recallrecommendations.

5.) Anesthesia: I understand that the use of local anesthetics has some potential risks including, but not limited to,temporary or permanent numbness, allergic reaction, cardiovascular and respiratory complications. I understandthat these risks are present, accept all inherent risks and consent to the use of local anesthetics.

6.) Photographic/Radiographic Image Release: I authorize and give permission to L. Patrick Grisanti II, DDS touse my photographs , radiographs, and models for the following purposes: research, educational, andpromotional purposes, including, but not limited to, use in publications, presentations, advertisements, internetand website content.

7.) Cancellation Policy: I agree to give 24 hour notice for cancellations or pay a potential broken appointment fee of$40.00. I understand that leaving a message after office hours the day before is not sufficient notice.

8.) Requesting Record Transfers: If you would like copies of your records transferred to another healthcareprovider, individual, or yourself, a signed written request must be given in advance.

I understand that dentistry is not an exact science and I do not expect guarantees in dental care. I have had the opportunityto discuss the risks and benefits of dental treatment with Dr. L. Patrick Grisanti II, DDS and I have had all of myquestions answered.

I have read the above and accept all inherent risks and conditions associated with treatment by Dr. L. Patrick Grisanti II,DDS and staff.

_______________________________________________________________ ________________etaDnaidrauGrotneraP/tneitaPfoerutangiS

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT/PARENT OR GUARDIAN GIVING CONSENT

Name: _________________________________________________________________

Address: _______________________________________________________________

Telephone:________________________________ E-Mail:_______________________

Social Security #:_______________________________

SECTION B: TO THE PATIENT/PARENT OR GUARDIAN-PLEASE READ THE FOLLOWINGSTATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protectedhealth information to carry our treatment, payment activities, and healthcare operations.Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decidewhether to sign this Consent. Our Notice provides a description of our treatment, payment activities, andhealthcare operations, of the uses and disclosures we may make of your protected health information, andof other important matters about your protected health information. A copy of our Notice accompanies thisConsent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. I wechange our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain thechanges. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at anytime by contacting:Contact Person: L. Patrick Grisanti II, DDSTelephone: (972) 772-9505Fax: (972) 722-7506Address: 2504 Ridge Road, Suite 204, Rockwall, Texas 75087

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice ofyour revocation submitted to the Contact Person listed above. Please understand that revocation of theConsent will not affect any action we took in reliance on this Consent before we received your revocation,and that we may decline to treat you or to continue treating you if you revoke this Consent.CONSENT:I have had full opportunity to read and consider the contents of this Consent form and your Notice ofPrivacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use anddisclosure of my protected health information to carry our treatment, payment activities, and health careoperations.

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal representative’s Name:______________________________ Relationship to Patient:___________

_______________________________________________________ _____________etaDnaidrauGrotneraP/tneitaPfoerutangiS

You are entitled to a copy of this consent after signed.