21334 Kuykendahl Rd. Suite B Spring, TX 77379 281-651-9494

Patient Information Last Name: ______________________________ Frist Name: _______________________ MI: ____ Date of Birth: ____________ Male / Female Single / Married Driver’s License # ______________________ Social Sec. #__________________________ Cell Phone: _______________________ Home Phone: ________________ Email: _______________________________________ Address: ________________________________________ City: __________________ State: _____ Zip Code: ________________ Emergency Contact Name: _________________________________ Relation: ________________ Phone # ___________________________

If you are filling this form out on behalf of another person, what is your relationship to that person? Name: _________________________________ Relation: ______________________ Date of Birth: _____________________

Reason For today’s visit? _____________________________________________________________________________________

How did you hear about us? Social Media Insurance Practice Website Internet Family / Friend / Coworker

Other: __________________________ Who can we thank for your visit: _______________________________________

Dental Insurance Information Subscriber’ Last Name: _________________________First Name: ________________________ Date of Birth: ________________ Employer: _______________________________ Name of Insurance Company: __________________________________________ Member ID: _______________________________________ Group # _________________________________________ Insurance Company Telephone Number: _________________________________________________________________

Dental History On a scale 1-10, with 10 being the highest rating: How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10 Where would you rate your current dental health? 1 2 3 4 5 6 7 8 9 10 Where do you want your dental health to be? 1 2 3 4 5 6 7 8 9 10

What would you like to change about your smile? Color Bite Chipped Teeth Spaces Crowding Smile Makeover Missing Teeth Whiter Teeth

Appearance Discolored teeth Worn teeth Misshaped teeth Crooked teeth Spaces Overbite

Pain / Discomfort Sensitivity (hot, cold, sweet) Broken teeth/ fillings Worn teeth Dry mouth

Function Grinding / Clenching Headaches Jaw joint (TMJ) pain / Clicking /

Popping

Bad Bite Speech Impediment Mouth Breathing Sore Muscles (neck, shoulders) Difficulty Opening or Closing Difficulty chewing on either side

Periodontal (Gum) Health Bleeding, Swollen Irritated gums Bad breath Loose tipped, shifting teeth Previous perio/ gum disease

Habits Thumb sucking Nail-biting Cheek/ lip-biting Chewing on ice/foreign objects Sleep Pattern or conditions

Sleep Apnea Snoring Daytime Drowsiness Bed wetting (for children)

Social Tobacco How much_____________ How

Long: _______________ Alcohol frequency

__________________________ Drugs Frequency:

__________________________ Previous Comfort Options

Nitrous Oxide / Oral sedation (pill) / IV sedatio

Please share the following dates: Last cleaning: ______________________ Last oral cancer screening: _____________________ Last complete X-rays: ______________________ What is the most important thing to you about your future smile and dental health? ____________________________________________________

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21334 Kuykendahl Rd. Suite B Spring, TX 77379 281-651-9494

Medical History Cancer

Type_______________ Chemotherapy Radiation Therapy

Cardiovascular Angina (chest pain) Artificial Heart Valve Heart Conditions Heart Surgery High Blood Pressure Low Blood Pressure Mitral Valve Prolapse Pacemaker Rheumatic Fever Scarlet Fever Stroke

Endocrinology Diabetes Hepatitis A / B / C Jaundice Kidney Disease Liver Disease Thyroid Disease

Gastrointestinal Ulcers (stomach) Gastrointestinal Disease

Hematologic/ Lymphatic Anemia Blood Disorders Bruise Easily Excessive Bleeding

Musculoskeletal Arthritis Artificial Joints Jaw Joint Pain Rheumatoid Arthritis

Neurological Anxiety Depression Dizziness Drug/Alcohol Addiction Fainting Seizures Psychiatric Illness

Respiratory Asthma Emphysema Respiratory Problems Sinus Problems Sleep Apnea Tuberculosis

Viral Infections AIDS HIV Positive HPV

Women Currently Pregnant Nursing

Medical Allergies Penicillin Amoxicillin Clindamycin Percocet Tylenol 3 Latex Local Anesthetics NSAID’s

Other Allergies: ____________________

__________________________________

__________________________________

Additional Comments: _______________

__________________________________

__________________________________

Are you under the care of a physician? Yes or No If yes please explain: ______________________________________________________________ _______________________________________________________________________________________________________________________ Physician Name: _______________________ Address: _____________________________________________ Phone #: _____________________ Have you had a serious illness, operation or hospitalization in the past 5 years Yes or No if yes please explain: ______________________________ _______________________________________________________________________________________________________________________ Are you taking or have you recently taken any prescription or over the counter medicine(s)? Yes or No, If yes please list all and why, including vitamins, natural or herbal supplements and / or dietary supplements: _____________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Have you ever in the past, or are you now currently taking any medications for Osteopenia / Osteoporosis or Bone Disease? If so, please list medications: ____________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Have you ever had surgery? If so what type? ___________________________________________________________________________________ _______________________________________________________________________________________________________________________ Consent: The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk I have read, understood and agree to the above terms and conditions. ______________________________ __________________________ ____________________ ______________________ Signature of Patient Print Name Date Dentist Signature

For completion by dentist only | Additional comments: ______________________________________________________________

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21334 Kuykendahl Rd. Suite B Spring, TX 77379 281-651-9494

Insurance and Financial Policy We are honored that you have chosen Spring Dental Arts, PLLC as your dental provider. We promise to do everything we can to give you and your family the best dental care possible. The following is a statement of our financial and Insurance Policy. Please read this carefully and do not hesitate to ask questions. We are here to help.

Financial policy

� Full payment is due at the time of service. � Acceptable forms of payment are cash, checks, and most major credit card. � There is a $50 fee for all returned checks. � We reserve the right to charge for appointments cancelled or broken without a 48 hour advanced notice. With this being said you must

speak to a Spring Dental Arts employee, a voicemail, email, or text is not acceptable. � Financing is available through CareCredit. � At our discretion, any unpaid balance after 90 days will be sent to collections and the patient is responsible for any fees associated with

the collection of the balance.

About Your Insurance

� As a courtesy to our patients, we will file your primary and secondary insurance claims for you. � We will not know the exact amount insurance pays until they respond to your claim. Regardless of what your insurance company pays,

you remain fully responsible for payment of your bill. Payment by your insurance company is never guaranteed. � Your insurance policy is a contract between you and your insurance company. We have no control over their decision and amounts they

decide to pay. � Before treatment, we will verify your insurance coverage and calculate your deductible and co-payments as accurately as possible. It is

important to be aware that all treatment plans, deductibles, and co-payments are only estimates based on the information your insurance company chose to provide. Your insurance company does not guarantee payment over the phone, internet, or fax.

� We will file your claim within 48 hours (usually same day) of date of service and your insurance will likely respond within 4 to 6 weeks.

I have reviewed the Insurance and Financial policy

_______________________________________________________________ _________________________________________________

Signature Date

21334 Kuykendahl Rd. Suite B Spring, TX 77379 281-651-9494

Notice of Privacy practice. This notice describes how health information about you may be used and disclosed. Please review it carefully. The privacy of your health information is important to us. OUR LEGAL DUTY : We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duty and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect in Monday, May 11, 2015 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our pr ivacy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. USES AND DISCLOSURES OF HEALTH INFORMATION Treatment: We use or disclose your health information to a dentist or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider perf ormance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your healthcare information for treatment, payment, or healthcare operations, you may give us writt en authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health informa tion any reason except those described in this notice. To your family and friends: We must disclose your health information to you, as described in the Patient Rights section in this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons involved in care: We may use or disclose healthcare information to notify, or assist in the notification o f (including identifying or locating) a family member, your personal representative or other person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstance, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, x-rays or similar forms if health information. Marketing health-related services: We will not use your health information for marketing communications without your written authorization. Required by law: We may use or disclose your health information when we are required to do so by law. Abuse or neglect: We may use or disclose your health information to appropriate authorities if we believe you are a possible victim of abuse or neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstance. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disc lose to correction institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we prov ide copies in a format other than photocopies. We will use the format that you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you $25.00 for each patie nt and postage if you want the copies mailed to you. If you request an alternative format, we will charge you a cost based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee structure. Disclosure accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last six years, but not before April 14, 2003. If you request this accounting more than once in a twelve month period, we may charge you a reasonable, cost based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We a re not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make this request in writing. Your request must specify the alternative means or location, and provide satisfactory explanations haw payments will be handled under the alternative means or location your request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: If you received this notice on our website or by electronic mail, you are entitled to receive this notice in written form . QUESTIONS AND COMPLAINTS If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may compl ain to us using the contact information listed at the end of this notice. You may also submit a complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a com plaint with us or with the U.S. Department of Human Services. Contact Officer: Kelly Vines 21334 Kuykendahl Road, Ste. B Spring, TX 77379 | (281) 651-9494 | Sda@krmdds.com

I have reviewed this office’s Privacy Practices ___________________________________________________ ______________________________ (Signature) (Date)

I will allow Spring Dental Arts to disclose my health information or any appointment concerns to: *IF YOU WANT US TO DISCUSS ANY INFORMATION TO YOUR SPOUSE OR PARENT PLEASE INCLUDE THEM ON THE LIST. IF NONE PLEASE WRITE NONE.

(First and Last Name) (Relationship) _________________________________________ _____________________________________ _________________________________________ _____________________________________

_________________________________________ ____________________________________

Adult Sleep & Breathing Questionnaire

Date: _________________________________

Patient 's Name: ______________________________________________

Patient's Date of Birth: ___________________________ Age: ___________

Male ______ Female ______

Have you ever had a sleep test administered? ______ yes ______no

If yes - when did you have your last sleep test? _______________________________

Have you been diagnosed with Sleep Apnea? ______yes ______no

Do you currently use a CPAP or Sleep Appliance for Sleep Apnea? ______yes ______no

Are you happy with your CPAP or Sleep Appliance? ______yes ______no

If you are not happy - why?

Yes No

How often do you get out of bed to use the restroom during the night?

Do you usually wake feeling tired and unrested?

Do you habitually snore?

Have you been diagnosed with Hypertension/High Blood Pressure?

Do you often suffer from waking headaches?

Do you regularly experience daytime drowsiness or fatigue?

Do you have blocked nasal passages?

Has anyone observed you stop breathing during your sleep?

Do you ever wake up choking or gasping?

Do you grind your teeth while sleeping?

Is your neck circumference greater than 40 cm/ 15.75" ?

Is your Body Mass Index (BMI) more than 35?

BMI Formula BMI = (your weight in pounds X 703)__________________

(your height in inches X your height in inches)