Welcome!

We are very happy to welcome you to Woodlands Family Dental and want you to know that we appreciate the chance to serve you and your family. Our office is focused on providing you withthe highest standards modern dentistry has to offer. We are delighted that you have chosen ouroffice to care for your dental needs.

Our mission is to glorify God in our community by providing an exceptional dental experience through hospitality, amenities, quality and efficiency. Our office combines the latest dental knowledge and technology together with care and compassion. We are proud to provide quality, family-oriented dental care to the adults and children of this community.

Enclosed you will find the necessary forms required to get you started as a new patient in our practice. Please complete them at your convenience and bring them with you to your appointment. 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.

Our office is located on 1400 Research Forest Dr., Suite 120. Feel free to contact us at 281-681-9600 if you have any questions or concerns.

We are very happy to welcome you to our state-of-the art office. We look forward to meeting youare your appointment!

Sincerely,

Your Woodlands Family Dental Team

Last Name First Name Middle Inital

Dental Registration

Patient Name

Social Security#Date

Address City State Zip

E-mail Sex (Circle One) M F Age Birthdate

Circle One: Married Widowed Single Minor

Patient Employer/School Occupation

Employer School/Address

)

Spouse’s Name Birthdate

Spouse’s Social Security# Spouse’s Employer

PATIENT INFORMATION

PHONE NUMBERS

Home ( )

Employer School/Phone(

Ext

Cell Phone (

)

Spouse’s Work () Ext

Best time and place to reach you

IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household)

Name Relationship

Home Phone ( ) Work Phone ( )

WHOM MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE?

Living MagazineReview ITFriend/Neighbor/RelativeName:

Please circle referral source:

VillaSportInternet - Google, Bing, etc. Woodlandsdental.comDrove By

Woodlandsonline.com FacebookYou Tube or VimeoOther

)

Work (

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems thatyou 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?

If yes, please explainYES NO

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 taken, Phen-Fen or Redux? YES NO If yes, please explain

Are you on a special diet? YES NO If yes, please explain

Do you use tobacco?

Do you use controlled substances?Are you experiencing pain or discomfort?

Are you in good health?

YES NO

YES NO

YES NO

Are you allergic to any of the following? (Please Circle)

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other

If other, please list

Women:Are you pregnant or trying to get pregnant? YES NOTaking oral contraceptives? YES NO

YES NO

Do you have, or have had, any of the following (Please Circle)

AIDS/HIV Positive Alzheimer’s DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise easily

CancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEmphysemaEpilepsy or SeizuresFainting Spells/DizzinessFrequent Cough

Frequent DiarrheaGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHemophiliaHepatitis A, B or CHerpes High Blood PressureHypoglycemiaIrregular Heartbeat

Kidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRenal DialysisRheumatic FeverRheumatism

Sinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Nursing? YES NO

Dental History Continued

How often to do you brush?

YES NO

Face Mouth Teeth Chin

Please circle to indicate if you have had any of the following:

Dental History Continued

How often to do you brush?

YES NO

Face Mouth Teeth Chin

Please circle to indicate if you have had any of the following:

Please circle ‘YES’ or ‘NO’ to indicate if you have had any of the following:

YES NO

How often do you floss?Do any of your teeth hurt? YES NO

Are you taking any medications to treat osteoporosis such as Fosmax, Aredia, Boniva, Zometa (Bisphosphonates) or Herbal remedies?YES NO

Is there anything about your teeth or smile you would like to change, such as dark teeth, crooked teeth, unsightly silver fillings, gummy smile,underbite, overbite, etc? YES NO

If so, please explain

Have you had any serious trouble associated with any previous dental treatment? YES NOIf so, please explain

Does food get caught in your teeth?Do you have frequent headaches, neck aches, or shoulder aches?Do you clench or grind your teeth?Have you experienced any pain or soreness in the muscles of your face or around your ear or jawTMJ/TMD?

YES NOYES NOYES NO

YES NO

Does your jaw click or pop?Have you ever had or been evaluated for orthodontic treatment before?Do you have any missing or extra permanent teeth?

Is there anything you would like the dentist to know? Have you ever had an injury to your (please circle)If so, please explain

Bad BreathBleeding GumsBlisters on lips or mouthBurning sensation on tongueChew on one side of mouthCigarette, pipe or cigar smokingClicking or popping jaw

Dry MouthFingernail BitingFood collection between teethForeign ObjectsGrinding TeethGums Swollen or tenderJaw pain or tiredness

Lip or cheek biting Loose teeth or broken fillingsMouth breathingMouth pain, brushingOrthodontic treatmentPain around earPeriodontal treatment

Sensitivity to coldSensitivity to hotSensitivity to sweetsSensitivity when bitingSores or growths in your mouth

How often do you brush?

DENTAL HISTORY

Reason for today’s visit

Former Dentist (Optional) City/State

Date of last dental visit Date of last dental X-rays

Dental Anxiety 0 (None) Past Dental Experience (Circle One) Excellent Positive Neutral Negative Horrible

>

10 (Max):

YES NO

YES NO

>

Office Policies

Appointment Policy

Welcome to Woodlands Family Dental! We are glad you have chosen us for you and your family’s dental care. Below you will find information on our office policies. Please fee free to ask one of our staff members any questions you may have. We look forward to providing you with state-of-the-art dental care.

Reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure to do so deprives our other patients from receiving needed dental care in a timely fashion. So that the dentist, our staff and our other patients will not be penalized by those who fail to keep scheduled appointments, our office policy stipulates that failure to give sufficient warning to keep a scheduled appointment, will result in a fee being charged.

-$30 for cleaning/doctor appointments and 48 hr advance notification-$150 for sedation appointments and at least 1 week advance notification

Our goal is to help remove financial barriers so our patients can receive the dental care they need and desire. We accept cash, checks, and money orders, Visa, MasterCard, Discover and American Express. We will even pay the interest on extended payment plans by offering CareCredit and Capital One Healthcare Financing at zero interest to you! CareCredit and Capital One offer many different plans that will allow your budget to provide the dental care you deserve.

Please note that any balances remaining on your account after 60 days will incur a 1.5% finance charge. Any account balances that reach 90 days past due will be turned over to American Credit Bureau for collection.

Payment is expected at the time of treatment unless other arrangements have been made prior to treatment.

payment options

Patient name: Date:

signature:

Notice to Insurance Patients

I understand that I am responsible for my balance with Woodlands Family Dental, including the following circumstances:

A. The treatment goes over my insurance company’s yearly maximum benefit.

B. My insurance company denies treatment.

C. I am not eligible for insurance.

D. The insurance benefits are less than what was indicated on Woodlands Family Dental Estimator.

E. I prevent or delay payment by no complying with requests for insurance forms and signatures.

F. I do not complete my treatment and it results in non-payment by my insurance company.

G. Lab costs are incurred due to my failure to appear at my appointments.

H. I RECEIVE MY INSURANCE CHECK AND DO NOT SEND IT TO WOODLANDS FAMILY DENTAL.

I HAVE READ AND UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGESNOT PAID BY MY INSURANCE. IF THERE IS A DIFFERENCE BETWEEN YOUR PORTION AND THE INSURANCE COMPANY’S PAYMENT, WE WILL SEND YOU A STATEMENT FOR THE BALANCE.

(Patient or Responsible Party)

(Print Patient or Responsible Party’s Name)

Please note that we are an out of network provider. However, we file claim forms electronically, provide postage for special claims and track the claims as a courtesy to our patients. We make every effort to accurately estimate your benefits prior to your appointment, however, most insurance companies do not give accurate estimate until the actual claim is received and processed. The benefits we are given by the insurance company are an ESTIMATE only and not a guarantee of payment.

On the day of your appointment you will be asked to pay the portion that we estimate the insurance company will not pay based on your coverage. We then file the claim and the insurance portion will be paid directly to our office. If the insurance check is sent directly to you, then you will be asked to pay the entire portion at the time of treatment.

Signed: Date:

Notice of privacy practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTYWe 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 duties, 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 (04/14/03), 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 the changes in our privacy practices and the new terms of our Notice effective for 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 privacy 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.

We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment

for 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, evaluation practitioner and provider performance, conducting training programs, accreditation,

certification, licensing or credentialing activities.

Your Authorization: In addition to our use of health information for treatment, payment or healthcare operations. Health-care operations, you may give us written authorization to use or disclose your health information to anyone for any purpose. If you give us authorization, you may resolve it in writing at any time. Unless you give us a written authorization, we cannot

use or disclose your health information for 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 of 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.

USES AND DISCLOSURES OF HEALTH INFORMATION

Persons Involved in Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another 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 th event of your incapacity or emergency circumstances, 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 judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person

to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of 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 disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, 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 the military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to any correctional institution or law enforcement official having lawful custody of protected health information to the extent necessary to avert serious threat to your health or safety or the health or safety of

others.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcard, 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 provide copies in a format other than photocopies. We will use the format your request unless we cannot practicably 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.

Disclosing 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 acitvities for the last 6 yeasrs but not before April 14, 2003. If your request this accounting more than once in a 12-month period, we may charge you a

reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health informa-tion. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an

emergency).

Acknowledgement of receipt of notice privacy practices

I, ,have received or reviewed a copy of this office’s Notice

of Privacy Practices.

Print Name

Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

*** You may refuse to sign this acknowledgement ***