Patient s First Name: Last Name: Middle Initial: Preferred Name: Home Phone: Work Phone: Cell Phone: Street Address:

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Patient’s First Name: _________________________________________ Last Name: ________________________________________________ Middle Initial: _____________ Preferred Name: ___________________________________ Home Phone: _____________________ Work Phone: ___________________ Cell Phone: ____________________ Street Address: _____________________________________________________________________________________________________

City: _____________________________________________________ State: _________________ Zip Code: ___________________

Patient’s Sex: Ο Male Ο Female Marital Status: ΟMarried Ο Single Ο Divorced ΟSeparated Ο Widowed

Birth Date: _______________________________ Age: ______ Social Security: ______________________________ Driver License: _____________________________ E-Mail:_____________________________________________________________

Emergency Contact Person: _________________________________________ Emergency Contact Phone: ____________________________________________ Referring Dentist/Physician/Person: __________________________________________________________________________________

Is Patient the ΟInsurancePolicy Holder ΟResponsible Party

Responsible Party (if someone other than the patient)

Patients Relationship to Responsible Party: Ο Self Ο Spouse Ο Child Ο Other

Responsible Party’s First Name: ______________________________________ Last Name: ____________________________________ Middle Initial: _____________ Responsible Party’s Street Address: _____________________________________________________________________________________________________

City: _____________________________________________________ State: _________________ Zip Code: ___________________

ΟResponsible Party is also Policy Holder for Patient Ο Primary InsurancePolicy Holder Ο Secondary Insurance Policy Holder

Primary Insurance Information

Name of Insured: _________________________________________ Patient’s Relationship to Insured: Ο Self Ο Spouse Ο Child Ο Other

Insured Date of Birth: ________________________

Information found on Dental Insurance Card Employer: _________________________________________ Group Number: __________________________ Insured Social Security or Member ID number: ___________________________________ Insurance Company: ____________________________________________ Insurance Company Address: ____________________________________________________________________________________________________________________________ City, State, and Zip Code: __________________________________________________________________________________________________________________________________

Secondary Insurance Information

Name of Insured: _________________________________________ Patient’s Relationship to Insured: Ο Self Ο Spouse Ο Child Ο Other

Insured Date of Birth: ________________________

Information found on Dental Insurance Card Employer:_______________________________________ Group Number: __________________________ Insured Social Security or Member ID number: ___________________________________ Insurance Company: ____________________________________________ Insurance Company Address: ____________________________________________________________________________________________________________________________ City, State, and Zip Code: __________________________________________________________________________________________________________________________________

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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 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.

Are you under a physician's care now? Yes No If yes, please explain: ____________________________________ Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: ____________________________________ Have you ever had a serious head or neck injury? Yes No If yes, please explain: ____________________________________ Are you taking any medications, pills, or drugs? Yes No If yes, please explain: ____________________________________ ____________________________________________________________________________________________________________________ Do you take, or have you ever taken, Phen-Fen or Redux? Yes No

Are you on a special diet? Yes No If yes, for what reason:____________________________________ Do you use tobacco? Yes No If yes, how much:________________________________________ Do you use controlled substances? Yes No If yes, what do you use:___________________________________ Women: Are you Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other

If other, please explain:________________________________________________________________________ Do you have, or have you had, any of the following?

AIDS/HIV Positive Yes No Cortisone Medicine Yes No Hemophilia Yes No Renal Dialysis Yes No Alzheimer's Disease Yes No Diabetes Yes No Hepatitis A Yes No Rheumatic Fever Yes No Anaphylaxis Yes No Drug Addiction Yes No Hepatitis B or C Yes No Rheumatism Yes No

Anemia Yes No Easily Winded Yes No Herpes Yes No Scarlet Fever Yes No

Angina Yes No Emphysema Yes No High Blood Pressure Yes No Shingles Yes No Arthritis/Gout Yes No Epilepsy or Seizures Yes No Hives or Rash Yes No Sickle Cell Disease Yes No Artificial Heart Valve Yes No Excessive Bleeding Yes No Hypoglycemia Yes No Sinus Trouble Yes No Artificial Joint Yes No Excessive Thirst Yes No Irregular Heartbeat Yes No Spina Bifida Yes No Asthma Yes No Fainting Spells/Dizziness Yes No Kidney Problems Yes No Stomach/Intestinal Disease Yes No Blood Disease Yes No Frequent Cough Yes No Leukemia Yes No Stroke Yes No Blood Transfusion Yes No Frequent Diarrhea Yes No Liver Disease Yes No Swelling of Limbs Yes No Breathing Problem Yes No Frequent Headaches Yes No Low Blood Pressure Yes No Thyroid Disease Yes No Bruise Easily Yes No Genital Herpes Yes No Lung Disease Yes No Tonsillitis Yes No Cancer Yes No Glaucoma Yes No Mitral Valve Prolapse Yes No Tuberculosis Yes No Chemotherapy Yes No Hay Fever Yes No Pain in Jaw Joints Yes No Tumors or Growths Yes No Chest Pains Yes No Heart Attack/Failure Yes No Parathyroid Disease Yes No Ulcers Yes No Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Psychiatric Care Yes No Venereal Disease Yes No Congenital Heart Disorder Yes No Heart Pace Maker Yes No Radiation Treatments Yes No Yellow Jaundice Yes No Convulsions Yes No Heart Trouble/Disease Yes No Recent Weight Loss Yes No

Have you ever had any serious illness not listed above? Yes No If yes, please explain:______________________________________

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Comments: _______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

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

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Northwest Periodontics

Stanley D. Halpern, D.D.S., P.C.

Practice Limited to Periodontics & Implants

220 Heritage Walk, Suite 102

Woodstock, Georgia 30188

Office 770-928-6655

Fax 770-928-6656

Dental Health Information

Reason for your visit to our office:_______________________________________________

Date of last dental visit:____/___/___ Date of last dental cleaning:___/___/___

Yes

No

Are you in pain? ... ____ ____

Are you under unusual stress at home/work? ... ____ ____

Have you had temporomandibular joint (TMJ) problems before? ……… ____ ____

Do you clench or grind your teeth? ... ____ ____

Do your gums feel tender or swollen? ……….. ____ ____

Do your gums bleed while brushing or flossing? (circle one or both) ……… ____ ____

Do you gag easily? ……… ____ ____

Do you have an electric tooth brush?... ____ ____

If yes, what name brand? __________________________

Have you ever been given Nitrous Oxide (laughing gas)? ____ ____

Do you like Nitrous Oxide? ____ ____

Are our teeth sensitive to: (Circle all that apply) Cold Hot Sweet Sour

Do you wear dentures upper/lower or partials upper/lower? (circle all that apply)

How often do you brush your teeth? ____________________________

How often do you floss your teeth? _____________________________

What type of toothpaste do you use? ____________________________

Texture of toothbrush you use? _______________________________

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Practice Limited to Periodontics and Implants

220 Heritage Walk

Suite 102

Woodstock, Ga. 30188

Office:(770) 928-6655

Fax:(770) 928-6656 ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

Date: _____________________________ I, (Please Print Name) ________________________________ have received a copy of this office’s Notice of Privacy Practices.

I authorize the release of medical/dental information. Including but not limited to diagnosis, records, examination, or treatment rendered to me and/or claims/account information. This information may be released to:

Please check and give name of all that apply

[ ] Spouse:_________________________________ [ ]Parent:________________________________________ [ ]Child:___________________________________ [ ]Other:_________________________________________ [ ] Or you prefer your information not to be released to anyone.

This release of medical/dental information will remain in effect until terminated by me in writing. Messages/Appointment Reminders

Please call: [ ] Home:_____________________________ [ ]Cell:_______________________________________ [ ] Work:___________________________ Ext:____________________

If unable to reach me:

[ ] You may leave a detailed message

[ ] Please leave a message asking me to return call [ ] Or ________________________________________________

The best time to reach me is (day & time) __________________________________________

Signature of Patient/Patients Responsible Party:______________________________________________________ For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained due to:

o Individual refused to sign

o Communications barrier prohibited obtaining the acknowledgement

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Practice Limited to Periodontics and Implants 220 Heritage Walk Suite 102 Woodstock, Ga. 30188 Office:(770) 928-6655 Fax:(770) 928-6656

Office Policies

We are committed to providing you with the best possible care. We emphasize our team’s relationship with you and your optimal dental health. We are pleased to discuss our professional fees with you at this time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibility.

- All patients must complete our “PATIENT INFORMATION FORM” before seeing the doctor.

- All applicable co-pays, personal balances, both current and prior are due at the time of service.

- WE ACCEPT CASH, CHECKS, DISCOVER, VISA/MASTERCARD and AMERICAN EXPRESS

Please circle your payment choice for today’s visit. REGARDING INSURANCE:

If you have insurance, we are happy to file your insurance claim as a courtesy. We will submit your insurance to reimburse you for your first visit. We will accept insurance assignment if we have a written pre-determination from your insurance company and will require you to pay the difference at the time of service. If you choose to have treatment done before a pre-determination has been received back from insurance, you will be responsible for 50% of the balance before treatment. Late Payment Charges are added to unpaid accounts after 60 days from date of service. If your insurance company pays more than the balance due, we will send a refund check to you in a timely manner.

INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. Not every dental service is a “covered” benefit in all insurance policies. Policy limitations vary from contract to contract. Failure to provide updated insurance information may result in denials, which the patient will be held responsible.

MISSED APPOINTMENTS:

Unless cancelled at least 48 hours in advance, it is our policy to charge $75.00 or 15% of the scheduled appointment fee, whichever is greater. This fee is not covered by insurance. After the first broken appointment, Northwest Periodontics reserves the right to require a deposit for any future appointments payable at the time of scheduling. This deposit is non-refundable if you cancel appointment with less than 48 notice. It will go toward co-pay when you keep your appointment.

LATE ARRIVALS:

Patients who are 15 minutes late to their appointments will be asked to reschedule, or if the doctor’s time allows will be worked in around our other patients. The Atlanta Area is very congested with traffic and construction, so please allow extra travel time.

YOUR SIGNATURE IS REQUIRED FOR US TO:

PROCESS ALL INSURANCE CLAIMS

TO ENSURE PAYMENT FOR SERVICES RENDERED

TO RELEASE MEDICAL INFORMATION TO INSURANCE COMPANIES

TO RELEASE INFORMATION TO OTHER MEDICAL/DENTAL PROVIDERS, WHEN NECESSARY,

FOR YOUR TREATMENT.

TO RECEIVE INFORMATION FROM OTHER PROVIDERS AND INSURANCE COMPANYS TO

FACILITATE YOUR TREATMENT

I authorize the release of all medical information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care. I assign all medical surgical benefits, including major medical to which I am entitled, to Stanley D. Halpern, D.D.S., P.C. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

Patients Name: __________________________________ Today’s Date:_____________________ (Please Print)

Responsible Party’s Name: ___________________________ (Please Print)

Responsible Party’s Signature: _________________________ Witness Signature: _____________________________

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