To help us meet all your dental healthcare needs, please fill out this formcompletely in ink. If you have any questions or need assistance, please ask us -we will be happy to help.

Date

Patient Information (CONFIDENTIAL) Soc. Sec. #

Name Birthdate Home Phone

Address City State Zip

Cell Phone Work Phone

Email

Check Appropriate Box: Minor Single Married Divorced Widowed Separated

If Student, Name of School / College City

How did you �nd our o�ce?

Person To Contact In Case of EmergencyName Phone

Responsible Party (FILL OUT FOR MINORS ONLY)Name of Person Responsible for this AccountAddress Home PhoneBirthdateEmployer Work Phone SSN#

Dental Insurance InformationName of InsuredBirthdate Social Security # Date EmployedName of Employer Union or Local # Work PhoneAddress of Employer CityInsurance Company Group # Policy/ID #Ins. Co. Address City

DO YOU HAVE ANY ADDITIONAL DENTAL INSURANCE Yes No IF YES, COMPLETE THE FOLLOWING:

Name of Insured

Birthdate Social Security # Date Employed

Name of Employer Union or Local # Work Phone

Address of Employer City

Insurance Company Group # Policy/ID#

Ins. Co. Address City

State/Prov.

FullTime

PartTime

Relationshipto Patient

Relationshipto Patient

State/Prov.

ZIP/Post.Code

ZIP/Post.Code

State/Prov.

ZIP/Post.Code

ZIP/Post.Code

State/Prov.

State/Prov.

Over Please Rev 9/09

Relationshipto Patient

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date _____________________________________

Do you have, or have you had, any of the following?

Yes No

Are you allergic to any of the following?

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 ______________________

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

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

If yes, please explain:Are you under a physician's care now? Yes No

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?

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

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent Diarrhea

Frequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood Transfusion

Breathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions

HerpesAnemiaAngina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

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

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

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

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

RheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStroke

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Rheumatic FeverRenal Dialysis

Radiation TreatmentsRecent Weight Loss

Yes NoYes NoYes No

Hepatitis B or C

High Blood Pressure

Yes NoYes NoYes NoYes No

HemophiliaHepatitis A

Pain in Jaw JointsParathyroid DiseasePsychiatric Care

Yes NoYes NoYes No

Hives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver Disease

Low Blood PressureLung DiseaseMitral Valve Prolapse

Yes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes No

Swelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Other

Aspirin

If yes, please explain:

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you

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

Do you use controlled substances? Yes No

Yes No

Have you ever been hospitalized or had a major operation?

Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? Yes No

Yes No

Metal Latex Sulfa drugsPenicillin Codeine Local Anesthetics Acrylic

High Cholesterol

Osteoporosis Yes No

Primary Medical Doctor’s Name

Address

Phone #

Have you ever had any serious illness not listed above Yes No N/A

Do you drink alcohol? If yes, how much?

Do you play sports? If yes, do you wear a mouth guard?

Do you want information regarding custom-made mouth guards?

*Condition may require medication N/A - Not answered by patient

Do you take any blood thinners or aspirin? Yes No

Informed Consent for Appointment Confirmation

Finger Lakes Dental Care is committed to providing the highest level of service and as such we have implemented a technology that will allow us to send text messages and/or emails. Please complete the form below so we know your wishes.

I Prefer to Receive Appointment Information Via

(Circle your Preferred Choice)

Home Answering Machine - Work Voice Mail- Cell Phone Message- Text Message – Email

Phone/cell number or email address: ____________________________________

Please note that there is a chance/risk that information when transmitted electronically may be disclosed to, or intercepted by unauthorized third parties. Please consider confidential communication via telephone or mail. By signing this form you are acknowledging this. Due to this acknowledgement Finger Lakes Dental Care will use/disclose only the minimum amount of protected information whenever possible. If at anytime you wish to revoke or change your preference regarding the use of text messaging, emails or voice messages you must do so in writing or call our offices at (585)394-1930.

Patient Name (Printed): _________________________________________________

Patient Signature:_____________________________________________ Date:__________

Jason R. Tanoory, DMD, FAGD Wendy Marshall, DDS

FINANCIAL POLICY

Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require that you read and sign. All patients either with or without insurance must provide our office with a valid social security number. If a valid social security number is not obtained, patient will agree to pay in full at time of service with either cash or credit/debit card (no checks). If you have insurance and a valid social security number is not provided the patient will also be responsible for submitting his/her own insurance claims. Payment / co-payment is due at the time service is provided. Our office accepts cash, personal checks, Discover, Visa, and MasterCard. For charges of $500 or greater, a 5% courtesy will be extended for full cash or check payment in advance of treatment. Outside financing is available upon request and approval. If you would like more information regarding these financing plans please ask. As a courtesy to you we will submit all insurance claims to your insurance provider for you. We will provide an estimate of the portion that your insurance will cover. However, it is NOT a guarantee that your insurance will pay exactly as estimated. We will of course, do all we can to make sure our estimate is as accurate as possible. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract. If payment is not received after 60 days or any claim that is denied by your insurance company, you the patient will be responsible for paying the full amount. Should the fees for professional services not be paid in accordance with the provisions herein finance charges can be applied to all past due amounts at the rate of $5.00 possibly more, per month. If the account is in default and turned over for collection, reasonable attorney’s fees, plus applicable finance charges and disbursements, allowances and costs provided by law shall be included in the computation of the amount due. All appointments must be verbally confirmed. Our office holds the right to remove any appointment from our schedule that is not verbally confirmed. Appointments not cancelled 48 hours in advance will require a deposit to reschedule, $50/hour scheduled. Returned checks will be subject to a $25 bank fee. We retain the right to refuse checks as payment. If you have any questions concerning this policy please ask our staff. I have read, understand and agree to the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to my dental office. _____________________ _________ ______________________________ Signature Date Signature of Guarantor, if a Minor & Date ______________________ ______________________________ Patient Name Print Name of Patient Guarantor, if a Minor

329 South Main St. * Canandaigua, NY * (585) 394-1930 * fingerlakesdental.com

PATIENT CONSENT FORM I understand that, under the Health Insurance Portability & 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 multiple healthcare providers who may be involved in that treatment directly and indirectly.

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

physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the option of receiving a full copy of your Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name: _________________________________________________ Signature: ____________________________________________________ Relationship to Patient: _________________________________________ Date: ________________________________________________________