Welcome to Ft Worth Cosmetic & Family DentistryThis confidential information will help us prepare for your visit

NAME (Mr Mrs Ms Rev Dr)

ADDRESS

YOU ARE

ZIP

HOME #

BIRTHDATE

WORK # CELL # E-MAIL

SSN#

I PREFER TO BE ADDRESSED AS

SPOUSE’S NAME

ADDRESS OCCUPATION

WORK # CELL # EMPLOYER

BIRTHDATE

EMPLOYER ADDRESS OCCUPATION

ACCOUNT INFORMATION

WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?

FAMILY MEMBERS SEEN AS PATIENTS HERE:

Single Married Divorced Widowed Separated

I have Dental Insurance to cover a portion of my feesPREFERRED PAYMENT ARRANGEMENTS (please check one)

Cash or personal check at time of service

Visa, MasterCard, Amex or Discover at time of service

CareCredit

NAME ON ACCOUNT

Self Spouse Other

We use an appointment reminder system that can send you convenient email, text messages and/or postcards. We may also call and if necessary leave brief voicemail messages.

If you would prefer NOT to receive routine reminders from us via certain methods, please indicate below:

No Text Messages No E-Mail No Cell Phone No Home Phone No Work Phone No Postcards

PLEASE CHECK ONE BOX IN EACH SECTION

I currently have no dental or jaw pain or sensitivity.

My mouth is very comfortable.

My mouth is moderately comfortable.

My mouth is uncomfortable.

I think my present state of dental health is excellent.

I think my present state of dental health is good.

I think my present state of dental health is fair.

I think my present state of dental health is poor.

I am aware of current dental treatment that I need.

I am unaware of current dental treatment that I need.

I am satisfied with the appearance of my teeth.

I am curious about changing the appearance of my teeth.

I am not satisfied with the appearance of my teeth.I currently have some dental or jaw pain or sensitivity.

Do You Have Delta Dental Insurance?

That is great! In fact, we have many wonderful patients covered by Delta Dental as they are one of the largest providers of dental insurance across the country. They are also one of the most rapidly changing insurance providers, and are constantly making changes to their way of doing business.

Most recently, they have begun sending most of their insurance payments directly to you, the patient. We are committed to making this as little of an inconvenience to you as possible. Due to the unusual nature of this company, the following outlines our policy regarding Delta Dental payments that are mailed directly to you:

We appreciate your cooperation with this policy. Ultimately, we wish to provide you with the highest quality lifetime dental care so that you may fully attain optimum oral health. Prompt payment of your portion and your insurance portion is an integral part of that care. Please let us know if you have any questions or concerns.

I have read, understand and agree to this policy.

We will do our best to estimate the correct benefit for all completed dental services.

We will only collect from you the estimated patient portion at the time of service.

We will file Delta Dental claims just as we do for all our insurance covered patients.

We will be notified when payment is sent to you, the patient. Upon that notification, you will be sent a statement for the full amount owed (which in some cases may be more or less than the payment you received from your Dental insurance).

Payment will be expected, in full, within 30 days of you receiving your insurance payment.

Due to the unusual arrangement with this particular insurance company and the significant trust we place in our patients to immediately send that insurance payment to us as payment for services already rendered, this policy will be strictly administered.

Any failure to pay the overdue balance will result in FULL payment being required at any future service appointments.

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

I, ____________________________________ have received a copy of this office’s.

Notice of Privacy Practices.

SIGNATURE DATE

SIGNATURE OF OFFICE REPRESENTATIVE DATE

** You may refuse to sign this acknowledgement

(Please Print Full Name)

FOR OFFICE USE ONLY

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

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Cavity Risk Questionnaire

We are committed to helping you prevent cavities. The process of prevention begins with understanding the factors that cause cavities that are present for you. Some of these factors you will have control over and we are happy to discuss ideas to manage them. Other factors are beyond your control, but can be managed by the addition of things like special toothpastes, rinses and mints.

Do you get Fluoride in your water, toothpaste or at the dentist?................................... NO1 YES

Do you eat sugary foods or drinks between meals?....................................................... YES2 NO

Have you or a close family member had cavities in the last _____ months?......... 0-123 12-24>24

Do you see a dentist regularly?.......................................................................................... NO4 YES

Have You Had Chemotherapy or Radiation?................................................................... YES5 NO

Have YOU had a cavity in the number of years?............................................................. <36 >3

Have you ever lost a tooth due to a cavity in the last 3 years?..................................... YES7 NO

Do you currently have braces?.......................................................................................... YES8 NO

Do you have a dry mouth?................................................................................................. YES9 NO

STOP HERE! (To Be Completed With Your Dental Hygienist or Dentist)

Total Caries Risk

Unusual Tooth Shapes....................................................................................................................... YES1 NO

Visible Plaque.......................................................................................................................... YES2 NO

Fillings Between Teeth............................................................................................................. YES3 NO

Poor Fitting Fillings or Crowns................................................................................................ YES4 NO

Exposed Tooth Roots.................................................................................................................. YES5 NO

Medications Causing Dry Mouth....................................................................................... YES6 NO

Other Factors.......................................................................................................................... YES7 NO

HIGHMODLOW

DENTAL COSMETIC QUESTIONNAIRE

NAME DATE

Dr. Green and her team LOVE to create and enhance smiles everyday in our practice. In order to evaluate your needs and desires as accurately as possible, please help us by answering the following questions, circle any words that may apply, and provide us with any additional information. If you have NO cosmetic concerns or desires...you may skip this section of the paperwork.

How do you rate your smile on a scale of 1-10 with 10 being the best smile?

How would you describe the color of your teeth? (Dark, Dull, Stained, Mismatched?)

Are your teeth crooked or out of line?

Are there spaces between your teeth you don’t like?

Have the biting edges of your teeth become uneven, worn down, or chipped?

Do you like the appearance of your dental fillings or crowns and do they match your other teeth?

Are any of your teeth missing?

Is there anything else about your smile or teeth that you don’t like, would like to change, or would like us to know about?

STOP HERE! (To Be Completed With Your Dental Hygienist or Dentist)

High Smile Line..........................................................................................................

Deep Bite...................................................................................................................

Functional Risk with Esthetic Treatment..................................................................

Ortho prior to Esthetic Treatment.............................................................................

Midline to Face..........................................................................................................

Upper Midline to Lower Midline...............................................................................

Overall Esthetic Risk..................................................................................................

HIGHMOD

HIGHMOD

HIGHMOD

HIGHMOD

HIGHMOD

HIGHMOD

HIGH

LOW

LOW

LOW

LOW

LOW

LOW

LOW MOD

FINANCIAL POLICY

Thank you for choosing us as your dental care provider. We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment. Payment is due at or before the time service is provided. Our office accepts cash, personal checks, Visa, Mastercard, Discover, and American Express. Third party financing is available through CareCredit, First Financial or Lending Club upon request and approval.

Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges incurred.

As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between, you, your employer and your insurance company. Our office is not a party to that contract.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office.

We ask that you pay the deductible and co-payment, which is the estimated amount not covered by your insurance company by cash, check, Visa, Mastercard, Discover or American Express at the time we provide the service to you.

Insurance payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at the time.

We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.

I have read, understand and agree to the above terms and financial policy. I authorize my insurance company to pay my dental benefits directly to my dental office.

SIGNATURE OF PATIENT/GUARDIAN DATEPRINT NAME

Do You Have Insurance?

Occlusal Risk Assessment Questionnaire

DO YOU HAVE PROBLEMS WITH YOUR JAW JOINT (PAIN, SOUNDS, LIMITED OPENING, LOCKING, POPPING)?

DO YOU FEEL LIKE YOUR LOWER JAW IS BEING PUSHED BACK WHEN YOU BITE YOUR TEETH TOGETHER?

DO YOU AVOID OR HAVE ANY DIFFICULTY CHEWING GUM, CARROTS, NUTS, BAGELS, PROTEIN BARS, OR OTHER HARD, DRY FOODS?

HAVE YOUR TEETH CHANGED IN THE LAST 5 YEARS (ie: BECOME SHORTER, THINNER, OR WORN)?

ARE YOUR TEETH BECOMING MORE CROWDED OR DEVELOPING MORE SPACES OVER THE LAST 5 YEARS?

DO YOU KNOW YOURSELF TO HAVE MORE THAN ONE BITE?

DO YOU CHEW ICE, BITE YOUR NAILS, USE YOUR TEETH TO HOLD THINGS, OR HAVE ANY OTHER CHEWING/BITING HABITS?

DO YOU CLENCH YOUR TEETH IN THE DAYTIME OR MAKE THEM SORE?

DO YOU HAVE PROBLEMS WITH SLEEP OR WAKE UP WITH SORENESS OR AWARENESS OF YOUR TEETH?

DO YOU WEAR OR HAVE YOU EVER WORN A BITE APPLIANCE?

DO YOU CLENCH OR GRIND YOUR TEETH WHEN YOU ARE STRESSED?

Significant wear present relative to age?................................................................................. LOW MEDIUM HIGH

Load test?..................................................................................................................................... LOW MEDIUM HIGH

Constricted chewing pattern?................................................................................................... LOW MEDIUM HIGH

Anterior wear?............................................................................................................................. LOW MEDIUM HIGH

Posterior wear?............................................................................................................................ LOW MEDIUM HIGH

Appliance therapy likely?......................................................................................................... LOW MEDIUM HIGH

STOP HERE — To Be Completed by your Dental Hygienist or Dentist:

Overall Occlusal Risk Assessment............................................................ LOW MEDIUM HIGH

Periodontal Risk Assessment Questionnaire

CigarettesAmounts per day Used for how many years If you quit, list what year

Cigars

Pipes

Chew

Frequent Urination

Excessive Hunger

Slow Healing Of Cuts

Excessive Thirst

Weakness And Fatigue

Unexplained Weight Loss

NAME DATE

DO YOU NOW OR HAVE YOU EVER USED THE FOLLOWING:

Tobacco UseTobacco use is the mostsignificant risk factor forgum disease.

Family history of heart disease

If you have any of these other risk factors it is especially important for you to always keep your gums as healthy as possible.

High cholesterol

Tobacco use

High blood pressure

Obesity

DO YOU HAVE ANY RISK FACTORS FOR HEART DISEASE OR STROKE?

Heart Attack/StrokeUntreated gum disease may increase your risk for heart attack or stroke.

Is your diabetes under control? Yes No

Are you prone to diabetic complications?

How do you monitor your blood sugar?

Who is your physician for diabetes?

Yes No

IF YOU ARE A PATIENT WHO HAS DIABETES:

Any family history of diabetes? Yes No

IF YOU ARE NOT A PATIENT WHO HAS DIABETES:

HAVE YOU HAD ANY OF THESE WARNING SIGNS OF DIABETES?

DiabetesGum disease is a common complication of diabetes. Untreated gum disease makes it harder for patients with diabetes to control their blood sugar.

Calcium Channel Blocker blood pressure medication. (such as Procardia®, Cardizem®, Norvasc®, Verapamil®, etc.)

Antiseizure medications. (such as Dilantin®, Tegretol®, Phenobarbital, etc.) Yes No

If you answered yes, are you still taking the anti-seizure medication?

Other Medication:

Other:

Immunosuppressant therapy (such as Prednisone, Azathioprine, Cyclosporins, Corticosteriods (Asthma-Inhalers), etc.)

Other:

Yes No

ARE YOU TAKING OR HAVE YOU EVER TAKEN ANY OF THE FOLLOWING MEDICATION:

Yes No

IS THERE AN IMMEDIATE FAMILY MEMBER(S) WHO CURRENTLY HAS OR HAD GUM PROBLEMS IN THE PAST? (E.G. YOUR MOTHER, FATHER, OR SIBLINGS):

MedicationsA side effect of some medications can cause changes in your gums.

Family History/GeneticsThe tendency for gum disease to develop can be inherited.

DO YOU HAVE A HEART MURMUR?

IF SO, DOES YOUR PHYSICIAN RECOMMEND ANTIBIOTICS PRIOR TO DENTAL VISITS?

Name of physician?

If you answered yes, it is especially important to always keep your gums as healthy and inflammation-free as possible to reduce the chance of bacterial infection originating from the mouth.

Heart Murmur,Artificial JointProsthesis

Pregnant

Nursing

Taking birth control pills

Infrequent care during previous pregnancies

Menopause

THE FOLLOWING CAN ADVERSELY AFFECT YOUR GUMS. PLEASE CHECK ALL THAT APPLY:

Estrogen Replacement Therapy/Hormone Replacement Therapy(such as Prempro®, Premarin®, Premphase®, Fosamax®, Actonel®, Evista®, Fortéo®, etc.)

DO YOU TAKE ANY OF THE FOLLOWING:

Females/WomenFemales can be at increasedrisk for gum disease at different points in their lives.

Women with osteoporosis havea greater risk for periodontal bone loss.

Yes No

DO YOU HAVE AN ARTIFICIAL JOINT? Yes No

Yes NoIf you have even the slightestamount of gum inflammation, bacteria from the mouth can enter the bloodstream and may cause a serious infection of the heart or joints.

Other:

ARE YOU UNDER A LOT OF STRESS?

DO YOU FIND IT DIFFICULT TO MAINTAIN A WELL-BALANCED DIET?

StressYes No

Yes No

High levels of stress can reduce your body’s immune defense

NutritionYour diet has the

potential to affect your periodontal

health.

ALL PATIENTS PLEASE COMPLETE THE FOLLOWING:

HAVE YOU NOTICED ANY OF THE FOLLOWING SIGNS OF GUM DISEASE?

Bleeding gums during toothbrushing

IS IT IMPORTANT TO KEEP YOUR TEETH FOR AS LONG AS POSSIBLE?

Yes

IF YOU HAVE MISSING TEETH, WHY HAVE YOU NOT HAD THEM REPLACED?

Not really

DO YOU LIKE THE APPEARANCE OF YOUR SMILE?

Yes No

DO YOU LIKE THE COLOR OF YOUR TEETH?

Yes No

DO YOUR TEETH KEEP YOU FROM EATING ANY SPECIFIC FOOD?

Yes No

Red, swollen or tender gums

Gums that have pulled away from the teeth

Persistent bad breath

Pus between the teeth and gums

Loose or separating teeth

Change in the way your teeth fit together

Food catching between teeth

PHYSICIAN NAME

OFFICE LOCATION

LIST ALL MEDICATIONS YOU TAKE (PRESCRIPTION AND OVER COUNTER)

OFFICE TELEPHONE

I see no obstacles

Time away from work or other obligations

Fear of possible discomfort, pain or injections

Fear because of past dental experiences

The cost of treatment

Other

MY CURRENT MEDICAL HEALTH IS:

Excellent Good Fair Poor

HAVE YOU EVER HAD ANY OF THE FOLLOWING:

Heart Attack

FOR WOMEN

Are you taking birth control pills

Heart Murmur

PLEASE CHECK ANY OF THE FOLLOWING DRUGS YOU HAVE USED AT ANY TIME:

Fosmax

Aredia

Boniva

Didronel

Actonel

Bisphosphonates

Zometa

Skelid

Scarlet Fever

Cancer

HIV/Aids

Fever Blisters

Stroke

Diabetes

Ulcers

Anemia

Arthritis

Fainting

Heart Surgery

Pacemaker

Hepatitis

Chemotherapy

Shingles

Cold Sores

Sinus Trouble

Tuberculosis

Colitis

Asthma

Emphysema

Glaucoma

Mitral Valve Prolapse

Rheumatic fever

Kidney Problems

Radiation Treatment

Artificial Joint

Artificial Valve

Epilepsy/Seizures

ARE YOU ALLERGIC TO, OR HAVE HAD DIFFICULTY WITH ANY OF THE FOLLOWING SUBSTANCES:

Penicillin

Aspirin

Sulfa

Tetracycline

Codeine

Erythromycin

Latex

Dental Anesthetic

Other Drugs

Psychiatric Problems

Drug/Alcohol Dependence

Hemophilia/Bleeding

Venereal Disease

Hospitalized

NONE OF THE ABOVE APPLY TO ME

No Yes

Are you pregnant No Yes

Are you nursing No Yes

Blood Transfusion Difficulty Breathing High/Low Blood Pressure Severe or Frequent Headaches

ARE YOU UNDER THE CARE OF A PHYSICIAN?

No Yes

CONCERNS I SEE ABOUT ACHIEVING OR MAINTAINING EXCELLENT DENTAL HEALTH ARE:

The information provided is accurate & complete to the best of my knowledge. I authorize the doctor to take X-rays, make study models, photographs, or other diagnostic materials deemed appropriate by the doctor to make a thorough diagnosis of my dental health condition. I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the services required for my dental health. I understand that the doctor will discuss treatment before it is initiated. I further authorize and consent that the doctor choose and employ such assistance as deemed fit.

Dr. Green attends and provides dental continuing education training, often using her patient’s cases and clinical information to provide relevant educational content. Unless I check the box below, I give permission to publish or use in print or electronic media any of my clinical photographs, x-rays, diagnostic information and findings, in whole or in part for educational purposes only. I understand I may withdraw this permission at any time by notifying Drs. Nikki Green, Robert Leedy & Associates in writing.

Do not use my clinical information for educational purposes

I understand that the responsibility for payment for professional services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless written financial arrangements have been made and signed by me. In the event of default I promise to pay interest on the indebtedness, together with any collection costs and attorney fees as may be required to effect collection.

Thank you for filling this form out completely. If you have questions regarding this form or any aspect of our dental practice please call us anytime.

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

Ft. Worth Cosmetic & Family Dentistry - Drs. Nikki Green, Robert Leedy & Associates - 817-737-6601