Daniel J. Vincento D.D.S., P.C.Comprehensive Dentistry

PATIENT INF'ORMATION

NAME:

PATIENT REGISTRATION

What would you like to be called?

ADDRESS:STREET CITY STATE ZIP

BIRTHDATE: TELEPHONE #:

EMAIL (we will not share):

MO DAY YR HOME OR CEI-I, WORK

MARITAL STATUS:

PLACE OF EMPLOYMENT:

BUSINESS ADDRESS:

OCCUPATION:

DENTAL INSURANCE CO:

SOCIAL SECURITY #:

Whom may we thank for referring you to our office?

GROUP#:

MEMBER ID #:

FAMILY INFORMATION

NAME:

HUSBAND ORFATHER WIFE ORMOTHER

ADDRESS:

TELEPHONE #:

EMPLOYER:

DENTAL INS CO:

PERSON TO CONTACT IN CASE OF EMERGENCY:NAME

AUTHORIZATION AND RELEASE - CONSENT FOR TREATMENT

PHONE #

To the best of my knowledge, the above information is complete and correct. I understand that is it my responsibility to inform Dr. Daniel Vincentif my minor child or I ever have a change in health.

I hereby authorize Dr. Daniel Vincent or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemedappropriate by the doctor to make a thorough diagnosis of my (or my child's) dental needs. Upon such diagnosis, I authorize Dr. Daniel Vincent toperform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide prop€r care.

I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agent embodies certain risks.I understand that I can ask for a complete recital of any possible complications.

EXPLANATION OF INSURED' S FINANCIAL RESPONSIBILITYI understand that I am financially responsible for all changes rendered to my dependents or me whether or not paid or reimbursed by my insuranceprovider(s). I authorize the use of my signature and assign benefits to Dr. Daniel Vincent on all insurance submissions. I understand that in theevent that my account becomes 45 days past due and is turned over to the United Collection of Georgia, Inc. that I will be responsible for allcollection expenses incurred. Thank you for choosing Vincent Dental.

Signature (Patient, Parent or Guardian):Payment is due in full at time of treatment unless prior anangements have been approved

Print Name: Date:

Daniel J. Vincent, D.D.S.

Comprehensive Dentistry

Heart (surgery, disass, amck)Chest Pain

Congenital Hffirt DBeE$e

Heart MurmurHigh Btood PresureMitralValve ProlaffiArtificlal Heart Valvs

Heart Pacemaker

Rheumatic FevsArtificial Joints (hiP,knee.e*)

Arthritis / Rheumatis'nCortisone MedicineSwollen Anldes

SFokeDiet * SPecial

Restricted

KidneY Trouble

UlcenDiabetesThyroid Problerns

EmphysemaChronic Cough

TuberculosisAstnmaAllergies or Hives

Latex AllerE}/ or Sensiuvity

Sinus Trouble

Radiation TheraPY

ChemdheraPYTumorsCancer

Hepatitus(B,C)VenerslDheageHerpes

cald Sores / Fever Biisters

H.l,V. Positive

AIDSBlood Trans*rion

Yes NoYes NoYes No

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Yes No

Yes No

Yes No

Yes No

Yes NoYes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

PAflENTS $gm*tURE:- ""'-- E:

Yes No

Yes l{oYes No

Yes NoYes NoYes NsYes NsYes floYes No

Yes No

Yes NoYes N0

Ycs No

Yes No

Yeo No

Yes No

Yes N*Yes NcYes NoYes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes NoYes No

Arne you taking ar*y rndicathns? Yes No

If so, Pleax

Are yw allergic m a*y medkations? Ys No

If so, Please Ljsn

Yes No When uras the hst UrnE yo't, sar+, your rnedical Dr ?

Physician's Name:***-_Telephore #:

Wsnen: Pregnant? Yes N0

NurslnE? Yef No

8C Pills? Yes hlo

Do you bke any of sle follortt{ng?

Fosamax Yes No

Aredia Yes No

Zorn€ta Yes No

Bonefos Yes No

MEDICAL HISTORY

please indkate the fidlowlng which lrrNl i16v€ hgd, or lmve at ffut€nt. Cirde *

Y85 " 6" Nou to each item'

HemWhilhSlckle Cell DlsseseBruise EasilyLiver OiseaseYellow.laurxCieNeurologkal DisotdersEdleFy$r Sela.resItervous'l AnxiolJs

SmokeUse AlcohoN

Psychiatric / Psychological Care

Dng Addiction

,dny other diiease or csndltion?

Staff Membefs $gna$re:- -' - ' ---Date:

Dental History

L How oflen do y*u brush your teeth? --

times/day times/ week2. How often do you floss your teeth? times/day" times/ w*ek3. Do your gurns bleed when you floss cr brush? (circle) Yes / hlo4. Have you ever been told you have gum disease? (cirele) Yes / Trjc

5. Any rnouth odor or unpleasant taste? {circ}e) Yes / Na6. Are any teeth loose? (circle) Yes / No7. Areyourtnethsensitiveta?(r:ircleall thatepply) Sweets / Cold I Heat / Pressure8. Have you ever had pain in your jarv joints {clicking" popping)? (circtre) Ycs I Nei

9. Do you wear retaincrs, nightguards or other appliances? (circle) Yes / No10.Have you ever had any: (check all that epply)

Orthodontic trcatm*nt Periotlontal treatment Clenching/Grinding

Vincent Dental * h{lssion Statement

Please Take Our "Smile Questionnaire"Vincent Derrtal places in a high emphasis on providing ceismetic dentistry tc enhance thebeauty and self-esteem of our paiients' smiles" Mclre tiran 25% of cur prectic€ production isgenerated by perfornring cosmetic services. Our rep*tation in the communitv es il c*smeticdental practice is based on superior quality or catre and attracts meny new patients interestedin cosmetic services to our office.

1. Rate your smile on a scale finm I to 10 (i 0 means totally satisfied):

| 2 3 4 5 6 7 8 9 10

2. What bothers you about your smile?

3. Are there any spaces you do not like? (circle) Yes / No4. Is there need for more spacing? (circle) Yes i ]ntro

5. Is crowding a problern? (circle) Yes / No6. Do you like the shape of y*ur teeth? (circle) Yes / l'tro7. Do you like the way your top and bottom teeth fit together? (circle) Yes / No8. Are there any discolor$d or otrd fillings that bother 3.'ou or that you don't like seeing in

your smile? (circle) Yes / No9. Are your teeth as bright as you like? (circle) Yes / l.Jo

10. Do you have any questions ahor.:t veneersn crowns, trridges, cosmetic bonding. replacingsilver fillings, implants or rvhitening? (circle) Yes i No

Daniel J. Vincent, DDS, pC3850 Holcomb Bridge Road, Suite 125 Peachtree Corners, GA 30094

(770) 449-s999www, dvincentdental.com

Financial Policy and Agreement

Denlal treatrnent is an exdlent lnvestrnent in an individual! rnedical and psychologicalwellbeing. Financia| consideratisr'ls sltould not be an sbstacle to cbtaining this important he&lr.h

service. Being sensltive lo the fact that difl'erent people have difilerent needs in fulfilling therrfinancial obligations, w* are providing fhe followjnE payrnsnt opdons;

1) Pay As You Go - For Your Convenience, You F4ay Chosse To Pay YourObliEation At Each Visit. We Accept Cash, Credit/D€bat Cards (t is8,MasterCard, American Expres*, Dicoover and CareCredit).

Z) Flexible Monthly Payment OBtions through CareCredit *Wth this option, you'll enjoy Sese benefils:

a) No Down Payment (sc no money needed tdayil)b) 3, 6 and 12 Month No Inter.est Optionsc) Convenient Low Monthly Payrnentsd) No Annual Fee or Prepayrnent penaltes

e) Credit Decision Received lrnmediately0 Quick and Eary Application in Our Office, Online

or Over the Phone

At the time of service, you are responsibie for trhe deductible as well as your peffentgge 0f lneservices rendered according to yaur insurance. trf your insurance has not paid in 60 days fronthe date of seruics, the full outstandir€-b,FlAq$: becomge vour responslbi,lty. We mustemphasize lhat as dental care providers our relalionship is with YOU. not your insuranrecompany or any other third-party payer. While fiiing insurance ls a counesy thet we extend,TFIE CHARGES ARE YOUR RtSPOIII$IBIUTY from the date *rat seruices are rendered.

We do not accept third-party liability cfairns dr.re h auto acclden$ er personal injury cases,

Therefore, it will bE nece$sary to pay when gertices are rendered; our sbff witl gladly provideyou with any documentation necessary fcr your reirnbursement,

Appointments over t hcur requi* a $50 deposit, this will go towsrds your co-payment,Appointments not canceled wlth a 48 llcurs Notics will be charged *$0 (paid by deposit)" We

are commiged to providing you with the best possible dentrl care while ke*ping our prices as

iow as possible. Due lo irrcreasing administrative ccsts and deiays in payme*ts related to fili*ginsurance, we irave adopted this financial poliry and agreemenL We want to be concerneC withyour dentistry, not fi nancial responsibilities"

How Will You Be PayinE Today? Credlt Card CareCredit Cash

Responsi ble PartY Sl g nature:

Date:

Daniel J. Vincentr D"D.S., F.C"

N otice of Prjvacy.,Pffi Ftiqeq

l. i understanG that my healthcare inforrnrticn concerning rny diegnosis, trca{ment, payrnent snc

insurance will be djsclosed when necessary for fillng my insunnce, and in con'rnunicailr,g witr:

other health professinnels sn the ccurge of rny treatnrent al ti:eir affices. Lirnited inforinalisr $illalso be disclosed to busincsses supportln3 the operations of tiris cffice such as dental or:lredirillabs, hospitals, 6ccountant, camputer suppo& billing p€r5annei, answ*rilg servic€s and

consultants. These businessss af* restrlctsd in the use and disclosure cf your infs:'rnaticrt by

governrnent authsrilies. If a farn;ly rne.nber or person is paying fcr youn heatfhcarc wilh yeu;"

knowledge, we may disclase inforff}6ti0i1 l0 lhat family mernbgi:0r per6sfl'

Z, I understand that my fiis are slgfed on shelves in the business office. Only steff Bnd lanitoriaipersonnel may have accesa to thls pffice drring nor"bustness hours, I understanci that this *ffr;cwill make every effort t6 keep my informatinn secure anC csrrect any rrielation cf r*y priuaey ifthis should occur'

3, 1 understand that I have lhe right to a(eess. copy 6r' ir:sBe{t and corredt my hotllhrarc;nformation, the right to re$lrict disclcsures anri obtain eri accourti{]g of discic,surcs. I have iheright to voice my coneer0$ about privaey to ihe practice anC/or the Secrefary of llealth ei:d

Human Services wilhin 180 days of my discovery of a discl*sure visialion witnoui fear efretaliatory acts by this offiee" I nnay eorr*d nny records in i,h* fprm of a lelter signed by n;*, Ialso have the right to revoke n1y authorizatlon fcr disclosure. {A rninimal i*e nf $CI.?O/pagt ','.'

be charged to me for copies 1 request.)

4. I understand thaf I wili rece:ve cornrnunicaiirn fnorn this cfflce in llre fcrrn of phone caiis snji:postcards to remind nre of an exjs(ing appoir|ment, sr lhet ia ;s time tc schecule an apporntntrriI may receive mail ccr:talning financie I lnformaiion, such as ledEers or biils, Comn'lr.lnicatior nayalso be sent to rne in th* forns of fax, e"rnails 0:' other electro*?c me$n$. i unders*nd thet il;message js left for rn€ to relurn a call, the rnessage y.rill conlain rhe ds{tor's narne and phon*number, Complele rnessase$ eoncerning my health lnfurn:atio* rnay b* leii. on rny personalhome or work voicemaii.

I have read and und*rstand thls offire psticy. : unCer*and that by signing this agresm*nt, i give my

permission for the use and disclosure of rny personal and health information in crder to carrl/ out

treatment, payment activilies, Ins*i-ance clairnsn and healthcare operalions. This offlce r"etains the r;;h: :.-,

revise the PrivacY PolicY'

Signaiure:**"-**

-***Date;Who may we discuss your account with:

(Name & Relationstrip to Patienl)

to sign, (pleese iniiial)o*xl have read this form and do not vllsh