PATIENT REGISTRATION

ID; Chart ID:

First Name: Last Name:

Patient Is: [j Policy Holder [j Responsible Party Preferred Name:

Responsible Party (if someone other than the patient)

DATE

Middle Initial:

First Name:

Address:

Last Name:

Address 2:

Middle Initial:

City, State, Zip:

Home Phone:

Birth Date:

Work Phone:

Soc Sec:

I I Responsible Party is also a Policy Holder for Patient Q Primary Insurance Policy Holder

Pager:

Ext: Cellular:

Drivers Lie:

i I Secondary Insurance Policy Holder

Patient Information

Address:

City:

Home Phone:

Sex: Q] Male

Birth Date:

E-mail:

I I Female

Address 2:

State / Zip:

Work Phone:

Marital Status: Q Married [j| Single

Age: Soc Sec:

Ext: Cellular:

LJ Divorced ["1 Separated | | Widowed

Drivers Lie:

[ 11 would like to receive correspondences via e-mail.

Employmentrn Full TimeStatus:

Student Status: Q Full Time

Medicaid ID:

Employer ID:

Carrier ID:

Section 2 Section 3

I j Part Time

I [PartTime

I I Retired

Pref. Dentist:

Pref Pharmacy:

Pref. Hyg:

Primary Insurance Information

Name of Insured:

Insured Soc. Sec:

Employer:

Address:

Address 2:

City, State, Zip:

Rem. Benefits:

Relationship to Insured: Q] Self lU Spouse I I Child I [other

Insured Birth Date:

Ins. Company:

Address:

Address 2:

City, State, Zip:

Rem. Deduct:

Secondary Insurance Information

Name of Insured:

Insured Soc. Sec:

Employer:

Address:

Address 2:

City, State, Zip:

Rem. Benefits:

Relationship to Insured: l] Self f]] Spouse □ child □ OtherInsured Birth Date:

Ins. Company:

Address:

Address 2:

City, State, Zip:

Rem. Deduct:

Patient Name:

North Babcock Dental^ PLLC

North Babcock Dental_iviedical History (Copy)Birth Date: Date Created:

Derdral History

Former Dentist?

City, State

Date oF Last Dental Visit |

Date oF Last Xrays |

How oFten do you Floss? |

How often do you brush? |

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 betaking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the Following questions.

Please CHECK all that apply:

Bad Breath

Bleeding Gums

Blisters on Lips or Mouth

: Finger Nail Biting

Grinding Teeth

Lip or Cheek Biting

Medical History

Yes O No

O Yes O NoOYes ONo

OYes ONo

O Yes O NoOYes QNo

Loose Teeth or Broken Fillings

Orthodontic Treatment

Pain around Ear

Periodontal Treatment

Sensitivity to Cold

Sensitivity to Heat

O Yes O No

O Yes O No

O Yes Q No

QVes QNo

O Yes Q No

O Yes O No

Sensitivity to Sweets

Sensitivity When Bitting

Frequent Headaches

Jaw, Head, or Neck Injuries

Jaw Clicking or Pain

Tooth Pain

O Yes O No

O Yes O No

OYes Qno

OYes QNo

Q Yes o No

O Yes O No

Are you CURRENTLY under Medical Treatment?

0CD

oz

0

IF yes j

Have you ever been hospitalized, had a major operation orserious illness?

>

0

Ono IF yes 1

Are you taking any medications, pills, or drugs? OYes ONo IF yes j

Do you use alcohol, cocaine or other drugs? OYes ONo IF yes 1

Do you take, or have you taken, Phen-Fen or Redux? OYes ONo IF yes 1Have you ever taken Fosamax, Boniva, Actonel or any othermedications containing bisphosphonates?

OYes ONo IF yes 1

Do you use tobacco? OYes Qno

Do you wear Contact Lenses? OYes ONo

Are you on a special diet? OYes Ono

Women: Are you...

□ Pt'egnant/Trying to get pregnant? { I Nursing? \ I Taking oral contraceptives?

Have you had any ALLERGIC REACTIONS to any oF the Following?i I Aspirin CH Codeine

: □ Latex □ SulFa Drugsr 1 Sedatives CZI Penicillin

Other Allergy? QYes Qno

Do you have, or have you had, any oF the Following?

i i Acrylic □ Metali I Local Anesthetics (eg. Novocaine) O) Iodiner 1 Barbiturates (Sleeping Pills)

IF yes

AIDS/HIV Positive OYes ONo Cortisone Medicine QYes Ono Hemophilia OYes Ono Radiation Treatments OYes Onoi Alzheimer's Disease OYes Ono Diabetes OYes Ono Hepatitis A O Yes Ono Recent Weight Loss OYes Ono: Anaphylaxis OYes Ono Drug Addiction OYes Ono Hepatitis B or C OYes

oz

Renal Dialysis OYes Qno; Anemia OYes Ono Easily Winded OYes Ono Herpes QYes Ono Rheumatic Fever OYes QnoAngina OYes Ono Emphysema OYes Ono High Blood Pressure OYes ONo Rheumatism OYes Ono

j Arthritis/Gout OYes Ono Epilepsy or Seizures OYes Ono High Cholesterol O Yes ONo Scarlet Fever QYes ONo

ArtiFicial Heart Valve OYes Ono Excessive Bleeding OYes Ono Hives or Rash OYes ONo Shingles OYes ONo

ArtiFicial Joint OYes Ono Excessive Thirst OYes Ono Hypoglycemia OYes Ono Sickle Cell Disease OYes ONoAsthma OYes Ono Fainting Spells/Dizziness QYes Ono Irregular Heartbeat OYes Ono Sinus Trouble OYes OnoBlood Disease OYes ONo Frequent Cough OYes Ono Kidney Problems QYes Ono Spina BiFida OYes QnoBlood TransFusion OYes ONo Frequent Diarrhea OYes ONo Leukemia OYes ONo Stomach/Intestinal Disease OYes ONoBreathing Problems OYes Ono Frequent Headaches OYes ONo Liver Disease OYes ONo Stroke OYes ONoBruise Easily OYes O No Genital Herpes OYes Ono Low Blood Pressure OYes Ono Swelling oF Limbs OYes Ono

: Cancer OYes ONo Glaucoma OYes Ono Lung Disease OYes ONo Thyroid Disease OYes ONo1 Chemotherapy OYes ONo Hay Fever OYes Ono Mitral Valve Prolapse OYes ONo Tonsillitis OYes ONoChest Pains OYes Ono Heart Attack/Failure OYes Ono Osteoporosis OYes ONo Tuberculosis OYes ONoCold Sores/Fever Blisters OYes Ono Heart Murmur OYes Ono Pain in Jaw Joints OYes Qno Tumors or Growths OYes QNo

Congenital Heart Disorder OYes ONo Heart Pacemaker OYes ONo Parathyroid Disease O Yes Ono Ulcers OYes OnoConvulsions OYes ONo Heart Trouble/Disease OYes Ono Psychiatric Care OYes ONo Venereal Disease OYes Ono

Yellow Jaundice OYes ONo

Have you ever had any serious illness not listed above? Q Yes O No IF yes 1

To the best oF my knowledge, the questions on this Form have been accurately answered. It is my responsibility to inForm the dental oFFice oF any changes in my MEDICAL STATUS. I herebyauthorize payment directly to NORTH BABCOCK DENTAL CARE For all insurance beneFits otherwise payable to me For services rendered. I understand that I am FINANCIALLY RESPONSIBLE For ALLCHARGES, not paid by insurance, and For all services rendered on my behalF. I authorize North Babcock Dental Care PROVIDERS or any supplier oF services in this oFFice to release the inFormationrequired to secure the payment oF beneFits. I authorize the use oF my signature below on all insurance documents.

Signature oF Patient, Parent or Guardian:

Date:

NORTi«^COCK—den^^Sare—

Smiles Make Smiles

Appointment Scheduling Policy

Patient Name: Date:

Our practice makes every effort to prepare for your dental visit to assure a comfortable andseamless experience. Oftentimes, preparation for your visit begins days in advance by coordinatingteam members, supplies, materials and laboratory availability. In order to deliver the higheststandard of care, we have instituted a "No Rush" policy. Though atypical, some dental proceduresmay take longer than expected to ensure the highest level of treatment for our patients. In theserare circumstances, there may be a waiting time upon arrival for your scheduled treatment visit.Rest assured that we will not "Rush" your treatment and the same meticulous care will be given toyou.

In this same spirit, we ask that you arrive promptly for your visits as we have allocated a specificamount of time dedicated for your treatment. We respectfully request a 48 hour notice for anymodifications to your scheduled appointment. This is to accommodate other patients of thepractice that are in need of priority treatment should you reschedule or cancel. We understandthat unexpected things may happen, but we ask your assistance in this regard.

As we are fully committed to preparing for your treatment visits, a partial financial commitmentin the form of a down payment is required to reserve treatment appointments with the doctor.Payment amounts vary depending on the treatment and time involved.Understand that you wiU be charged a $25 cancellation fee if you cancel an appointment orNO SHOW with less than 48 hours of notice. Any combination of either three consecutivecancellations or NO SHOWS within 24hrs of your appointment and you will forfeit the downpayment amoimt as a practice fee and any remaining credit will be refunded to you and futuretreatment will terminated. Please understand, for a typical 60-minute appointment, tardiness ofeven 10 minutes can significantly impact the time and quality of care that you deserve. Pleaseunderstand that if you are more than 10 minutes late, your treatment may be rescheduled or requiremultiple visits to ensure the highest quality care.

Cancellation fees and forfeit of the down payment are in no way a means to punish our patientsfor unexpected emergencies (i.e.. medical emergency, accident, sudden illness). The fees listedabove do not apply to these unforeseen circumstances imless they are an ongoing issue. If you arehaving ongoing issues with cancelling/rescheduling your procedures, we will understand that youroral health is not a current priority and will assist in helping you find a practice that better fits yourscheduling needs. Minimizing modifications to scheduled dental treatments are one of thelandmarks in allowing our office to continue to offer the highest quality dental care with the mostaffordable fees North Babcock Dental.

I have read and understand the Appointment Policy mentioned above and agree to abide by thesepolicies as stated.

Patient Signature Bate

Dr. Luis Galvan Dr. Otto Herod

5970 Babcock Road ♦ San Antonio, Texas 78240 ♦ 210-691-1200

NBDC121920160HLG

NORTm^COCK—dem^^Sare-

Smiles Make Smiles

Appointment Confirmation Poiicy

All appointments must be confirmed 24 hours in advance, if we are unable toconfirm your appointment via; Text message, email or by phone, we reservethe right to double-book your appointment & or cancel your appointment.

Our office offers several different options for appointment confirmation.

Please let us know what method{s) of confirmation work best for you.

Please select ALL methods of confirmation you would like:

□Text message(Please provide cell phone number you would like to receive text messages at)

□Email Address

□ Phone call only(Please provide phone number you would like to receive phone call at)

informed Consent for PhotographsI understand that photographs, X-rays, and other records may be made during the course of myexamination, treatment, and follow up care.

□ I give my permission for such items to be used for purposes of research,education, or publication in professional journals.

□ I do not give my permission for such items to be used for purposes of research,education, or publication in professional journals. I only Allow for Patient Chart Photo Only,

I have read, and I understand the appointment confirmation poiicy andinformed consent for photographs of North Babcock Dental Care.

Patient/Guardian's signature Date.

Patient's Name

Dr. Luis Galvan Dr. Otto Herod5970 Babcock Road ♦ San Antonio, Texas 78240 ♦ 210-691-1200

NBDC121920160HLG

NORXI^BCOCK—DEN^^^RE-

Smiles Make Smiles

Financial Policy

Thank you for choosing NORTH BABCOCK DENTAL. It is exciting to have you join ourpatient family! We believe in the importance of quality dental care and will strive to provide thebest dental treatment possible. Also, we understand the financial limitations that influence yourchoice of care and want to assure you of our flexible approach by offering several payment options.We accept the following methods of payment:

CASH, CHECK, AMERICAN EXPRESS, DISCOVER, MASTERCARED, VISA, & CARE CREDIT

Terms and Conditions

Payment terms: North Babcock Dental requires payment in full prior to beginning of your treatment. Oncea customized treatment plan has been formulated for your dental needs, a staff member will discuss furtherpayment options.

For plans requiring multiple appointments, altemative payment arrangements may be provided. For larger,more comprehensive treatment plans of $200 or more, a 25% deposit is required to secure your initialtreatment appointment. ALL SATURDAY APPOINTMENTS must be Pre-Paid prior to the day ofyour scheduled treatment.

Patient Initials

FOR OUR PATIENTS WITH DENTAL INSURANCEWe will be happy to work with you and your insurance carrier to maximize your benefits. Payment ofinsurance deductible and co-insurance amounts are expected at the time of your visit. If you choose toassign your insurance benefit directly to us we will then bill your carrier for the balance of your payment.If payment has not been received from your insurance carrier within 60 days, the balance owed becomesvour responsibility. Some Insurance companies send payments directly to patients instead of to thedental provider. It is your responsibility to submit payment for these services rendered at NorthBahcock Dental

Cancellation Policv: Understand that you will he charged a $25 cancellation fee if you cancel anappointment or NO SHOW with less than 24 hours of notice. A reservation fee will be required whenscheduling an appointment that was cancelled. We require a 48-hour notice if changes need to be made toyour scheduled appointment as we schedule by procedure and staff our office accordingly for the daysdental procedures.

Returned Check Fee: A fee of $25 is charged for returned checks by your bank.

Acknowledgment; I have read and understand the terms of the above Financial Policy.

Patient/Guardian's signature , , . . . . Date.

Print Patient Name

Dr. Luis Galvan Dr. Otto Herod

5970 Babcock Road ♦ San Antonio, Texas 78240 ♦ 210-691-1200

NBDC121920160HLG

NORHTOSCOCK—DEN^^tARE-

Smiles Make Smiles

HIPAA PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information.

These rights are given to me under the Health Insurance Portability and Accountability Act of1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my

protected health information to carry out:

1. Treatment (including direct or indirect treatment by other healthcare providers

involved in my treatment)

2. Obtaining payment from third party payers (e.g. my insurance company)

3. The day to day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of

Privacy Practices, which contains a more complete description of the uses and disclosures of myprotected health information, and my rights under HIPAA. I understand that you reserve theright to change the terms of this notice from time to time and that I may contact you at any time

to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health informationis used and disclosed to carry out treatment, payment, and health care operations, but that youare not required to agree to these requested restrictions. However, if you do agree, you are thenbound to comply with this restriction. I understand that I may revoke this consent, in writing, atany time. However, any use or disclosure that occurred prior to the date I revoke this consent isnot affected.

Please list any parties who can have access to your health Information (tms includes step parents,grandparents, spouse, family member, and any care takers who can have access to this patient's records):

Name: Relationship:

Name: Relationship:

Print Patient Name: Date:.

Patient Signature: ■ Relationship to Patient:

Dr. Luis Galvan Dr. Otto Herod

5970 Babcock Road ♦ San Antonio, Texas 78240 ♦ 210-691-1200

NBDC121920160HLG

HiPAA NOTICE OF PRIVACY PRACTICES for North Babcock Dental Care

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to giveyou notice of our privacy practices. This Notice describes how we protect your health information and what rights you

have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care

operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment

for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor orclinic for other health care or services; or getting copies of your health information from another professional that youmay have seen before us.

Examples of how we use or disclose your health information for payment purposes are: asking you about your healthor dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts(either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative andmanagerial functions that we must do to run our office. Examples of how we use or disclose your health informationfor health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participationin managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If weneed to disclose your health information outside of our office for these reasons, we usually will not ask you for specialwritten permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission.Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

o when a state or federal law mandates that certain health Information be reported for a specific purpose; for public healthpurposes, such as contagious disease reporting. Investigation or surveillance;and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;

• disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;• uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or

Medlcald; or for Investigation of possible violations of health care laws;« disclosures for judicial and administrative proceedings, such as In response to subpoenas or orders of courts or

administrative agencies;

• disclosures for law enforcement purposes, such as to provide Information about someone who Is or Is suspected to be avictim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;

• disclosure to a medical examiner to Identify a dead person or to determine the cause of death; or to funeral directors toaid In burial; or to organizations that handle organ or tissue donations;

• uses or disclosures for health-related research;

• uses and disclosures to prevent a serious threat to health or safety;

• uses or disclosures for specialized government functions, such as for the protection of the president or high-rankinggovernment officials; for lawful national Intelligence activities; for military purposes; or for the evaluation and health ofmembers of the foreign service;

• disclosures of de-ldentlfled Information;

• disclosures relating to worker's compensation programs;

• disclosures of a "limited data set" for research, public health, or health care operations;

• Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;

® disclosures to "business associates" who perform health care operations for us and who commit to respect the privacyof your health Information;

UNLESS YOU OBJECT, WE WOLL ALSO SHARE RELEVANT eNFORWIATBON ABOUT YOUR CARE

WITH YOUR FAMILY OR FRIENDS WHO ARE HELPING WITH YOUR DENTAL CARE.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. Wemay also call or write to notify you of other treatments or services available at our office that might help you. Unlessyou tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder messageon your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorizationform." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate theauthorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea forus to send your information to someone else. Typically, in this situation you will give us a properly completedauthorization form, or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign theauthorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we havealready acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named atthe bottom of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:• ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or

health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that youwant. To ask for a restriction, send a written request to the office contact person at the address, fax or Email shownat the bottom of this Notice.

® ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, bymailing health information to a different address, or by using E mail to your personal E Mail address. We willaccommodate these requests if they are reasonable, and if you pay us for any extra cost, if you want to ask forconfidential communications, send a written request to the office contact person at the address, fax or Emaii shownat the bottom of this Notice.

• ask to see or to get photocopies of your health information. By law, there are a few limited situations in which wecan refuse to permit access or copying. For the most part, however, you will be able to review or have a copy ofyour health information within 30 days of asking us (or sixty days if the information is stored off-site). You may haveto pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructionsabout how to get an impartial review of our denial if one is legally available. By law, we can have one 30-dayextension of the time for us to give you access or photocopies if we send you a written notice of the extension, ifyou want to review or get photocopies of your health information, send a written request to the office contactperson at the address, fax or Email shown at the bottom of this Notice.

• ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amendthe information within 60 days from when you ask us. We will send the corrected information to persons who weknow got the wrong information, and others that you specify. If we do not agree, you can write a statement of yourposition, and we will include it with your health information along with any rebuttal statement that we may write.Once your statement of position and/or our rebuttal is included in your health information, we will send it alongwhenever we make a permitted disclosure of your health information. By law, we can have one 30-day extensionof time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us toamend your health information, send a written request, including your reasons for the amendment, to the officecontact person at the address, fax or Email shown at the bottom of this Notice.

• get a list of the disclosures that we have made of your health information within the past six years (or a shorterperiod if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health careoperations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some otherlimited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, youwill have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but bylaw we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send awritten request to the office contact person at the address, fax or Email shown at the bottom of this Notice.

« get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got oneelectronically or in paper form already. If you want additional paper copies, send a written request to the officecontact person at the address, fax or E mail shown at the bottom of this Notice.

North Babcock Dental Care 5970 Babcock Road San Antonio TX 78240

Office: 210-691-1200 Fax: 210-691-5064 Email: northbabcockdental@gmall.com