Date: _________________ SS# ________________

_____________________________________________________________________________________

First Name Last Name DOB Male/Female

_____________________________________________________________________________________ Address City State Zip Code _____________________________________________________________________________________

Home Phone # Cell Phone # E-Mail Address

_____________________________________________________________________________________

Employer Work Phone #

_____________________________________________________________________________________

Marital Status (single, married, divorced, widowed) Spouse's Name DOB Is the patient a child under the age of 21? Yes _______ No _______ What is the most convenient appointment time? _____________________________________________________

Who may we thank for referring you to our office? ____________________________________________________

Our office makes use of text messages every now and then as a way for you to conveniently be notified of any

promotions that we offer. If you do not wish to receive these notifications please let us know.

Tell us About Yourself:

Are your teeth sensitive to hot, cold and/or sweets? Yes _______ No _______ Is your present dental health good? Yes ______ No _______ Does food catch between your teeth? Yes ______ No _______ Do your gums bleed when brushing? Yes ______ No _______ Have you ever had any periodontal (gum) treatments? Yes ______ No______ Have you noticed any gum swelling? Yes ______ No ______ Do you have an unpleasant taste or odor in your mouth? Yes ______ No _______ Have you ever taken Fosamax, Actonel, or any other biphosphonate? Yes ______ No _______ Do you ever avoid any part of your mouth while brushing? Yes ______ No ______ Are you experiencing mouth pain? Yes ______ No ______ Are you deeply concerned about the finances required to return to excellent dental health? Yes _____ No ______ Are you apprehensive about dental treatment? Yes ______ No ______ Have you ever had a reaction to local anesthetic? Yes ______ No _______ Do you smoke? Yes ______ No ______ Have you ever had any teeth removed? Yes _____ No ______ Do you wear dentures? Yes ______ No _______ Are you aware of clenching and grinding your teeth? Yes ______ No _______ Have you ever had orthodontic treatment? Yes _______ No _______ Do you regularly use dental floss? Yes _______ No _______ When was your last dental appointment? Month __________________ Year _________ Do you snore? Yes _______ No _______ Have you ever had TMJ (jaw joint) problems? Yes ______ No _______ What is your reason for today's visit? _______________________________________________________________ Please share with us anything that will help make your visits to our office more comfortable including special needs _____________________________________________________________________________________________

How do you feel about your smile?

Most people have heard the term "Cosmetic Dentistry." What exactly does it mean? It simply means

anything that is done to the teeth to enhance the way they look. Altering the cosmetics of the teeth can

have an enormous impact on one's overall appearance and self-confidence. In an effort to learn more

about how our patients feel about their smile, please take a moment to fill out this questionnaire.

Name: _____________________________________________________

1) How do you generally feel about the appearance of your teeth?

Great _______Good _______ Self-conscious at times _______ Poorly _______ Don't Care ______

2) Are you unhappy and/or insecure about the appearance of teeth when you smile?

Yes _______ No _______ Comments ___________________________________________________

_________________________________________________________________________________

3) Do you have crooked teeth that bother you?

Yes _______ No _______ Comments ___________________________________________________

_________________________________________________________________________________

4) Are you unhappy with the color of your teeth?

Yes _______ No _______ Comments ___________________________________________________

_________________________________________________________________________________

5) What are the things that would stop you from enhancing your smile?

Money _______ Time _______ Fear of Pain _______ Lack of Concern ______ None _______

New Patient Account Information

Please let us know who will be responsible for your dental expenditures?

_____________________________________________________________________________________

Last Name First Name Social Security #

_____________________________________________________________________________________

Address City State Zip

We kindly accept payment by cash, check, Visa, MasterCard, American Express, Discover, Care Credit

and Lending Club.

Your initial visit will entail a comprehensive examination and any necessary radiographs to diagnose

dental disease or a limited examination and treatment to relieve pain or discomfort. Payment for this

visit is expected at the time of service. After all data has been gathered, a follow up consultation

appointment may be necessary to discuss our findings and fees. We invite you to discuss any questions

regarding our services and fees.

We understand that your time is very valuable and as such we make appointments to suit your specific

needs and available times. We are committed to treating your time with the utmost respect and we ask

the same from you. We require 48 hours notice if you need to change an appointment and a courtesy

call of you are going to be more than 5 minutes late. Cancellations, broken appointments and lateness

affect other patients as well as the office schedule. To minimize the risk, we ask that you schedule

appointments at times that you will not be affected by other interruptions. We do realize that

emergencies may arise and we will make every effort to accommodate your needs; however, a fee of

$50 for a dental hygiene appointment and $100 for a doctor appointment may be incurred for broken

appointments and last minute, non-emergency cancellations.

I authorize and necessary radiographs and supportive documentation necessary to allow the doctors to

diagnose my dental needs. I am aware that, if necessary, a consultation/treatment planning

appointment will be scheduled so that I can make an informed decision on additional treatment.

Interest or billing charges of 1.5% a month will be applied to overdue accounts after 60 days. Any

collection costs, including all court and attorney fees, will be charged to delinquent accounts and will be

reported to credit rating agencies.

I have read and understand the above information. By my signature below I consent to the information

described above.

_____________________________________________________________________________________

Patient or Parent (if minor) Date

Dental Insurance Information

We are pleased to assist you in making an investment in your dental health by submitting your insurance claims.

Please complete the information below so that we can make sure that you get the benefit reimbursement you are

entitled to under your plan.

________________________________________________________________________________________________________ Policy Holder Policy Holder's Employer ________________________________________________________________________________________________________ Primary Insurance Company ID # of Policy Holder's Social Security Number Group # ________________________________________________________________________________________________________ Insurance Company's Address City State Zip ________________________________________________________________________________________________________ Secondary Insurance Company ID # of Policy Holder's Social Security Number Group # ________________________________________________________________________________________________________ Insurance Company's Address City State Zip ________________________________________________________________________________________________________ Relationship to the Policy Holder Policy Holder's Date of Birth F/T College Student (Yes or No)

Most plans have limitations (deductibles, yearly maximums and exclusions). In order for us to properly estimate benefits, please make available your insurance booklet (provided by the employer). The insurance plan is a benefit provided by your employer to you and an agreement between your employer and the insurance company on your behalf. We will file your claims as a courtesy to you and accept the assignment of benefits allowing payment to us if that benefit is available under your particular plan. What your insurance pays is a benefit to you and does not affect your responsibility to your office, even if it does reduce your out of pocket expense. As with all our patients, we will discuss the fees for treatment prior to rendering the service. We can assist you in determining your possible benefit for your dental treatment as provided under your plan. I have insurance coverage with ___________________________, and I am releasing all benefits to Distinctive Dentistry of Long Island, if any, otherwise payable to me for all services rendered. I understand that I am financially responsible for all charges incurred whether or not paid by my insurance company, including deductibles, co-payments and non-coverage charges. I hereby authorize the release of all necessary information and documents (x-rays etc) to secure payment of benefits. I am responsible to verify my own insurance coverage and know my benefits and do not hold Distinctive Dentistry of Long Island responsible for this information. By my signature below, I state that I understand the financial policy of Distinctive Dentistry of Long Island and realize that insurance assignment is a courtesy extended by Distinctive Dentistry of Long Island. I understand that I am ultimately financially responsible for payment of all services rendered, regardless of whether the insurance company denies payment for any reason to this office.

________________________________________________________________________________________________________ Patient Date ________________________________________________________________________________________________________ Parent (if minor or child under 18) Date

________________________________________________________________________________________________ Last Name First Name Middle Initial DOB Male/Female Do you have a Primary Care Physician? Yes No ________________________________________________________________________________________________ Primary Care Physician's Name Phone Number Date of last visit Are you currently under the care of a physician? Yes No If yes, please explain: ______________________________ ________________________________________________________________________________________________ Are you taking any prescription or over-the-counter drugs? Yes No If yes, please list each one: _________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Pharmacy Name Pharmacy Address Pharmacy Phone Number Are you taking any medication for bone strength? Yes No Such as: Fosamax Boniva Actonel Other __________ Do you smoke tobacco? Yes No Are you allergic to any of the following? Yes No If yes, please circle: Aspirin Tetracycline Dental Anesthetic Penicillin Latex Jewelry/Metals Other __________ Have you ever had to pre-medicate for dental work? If so, explain __________________________________________ ________________________________________________________________________________________________ FOR WOMEN: Are you taking birth control pills? Yes No Are you pregnant? Yes No If yes, how many weeks? _________________________ Are you nursing? Yes No Have you ever had any of the following diseases or medical issues? If so, please check all that apply.

o Abnormal Bleeding o Allergies o Anemia o Artificial Bones/Joints o Artificial Valves o Asthma o Blood Transfusion o Cancer o Chemotherapy o Congenital Heart

Defect o Diabetes o Difficulty Breathing o Drug/Alcohol Abuse o Emphysema

o Epilepsy/Seizures o Epinephrine Sensitive o Fainting Spells o Fever Blisters/Herpes o Glaucoma o Heart Attack/Stroke o Heart Murmur o Heart

Surgery/Pacemaker o Hemophilia/Abnormal

Bleeding o Hepatitis o High/Low Blood

Pressure

o HIV +/AIDS o Hospitalized for Any

Reason o Kidney Problems o Radiation o Rheumatic/Scarlet

Fever o Severe/Frequent

Headaches o Shingles o Sinus Problems o Tuberculosis (TB) o Ulcers/Colitis o Venereal Diseases

Please list any serious medical condition(s) that you have ever had: __________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Patient Signature Date

NOTICE OF PRIVACY PRACTICES

Distinctive Dentistry of Long Island

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 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 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 January 5, 2018, 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 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 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. USES AND DISCLOSURES OF HEALTH INFORMATION 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 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 performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written 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 in writing 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 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. 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 the 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 military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional 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 voice mail 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 provide copies in a format other than photocopies. We will use the format you 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. 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 $0.15 for each page, $25.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge 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, not before January 5, 2018. If you 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. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are 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 your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you 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 receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. 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 complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services 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 complaint with us or with the U.S. Department of Health and Human Services. Telephone: 1-631-473-3094 E-mail: distinctivedentistryli@gmail.com Address: 140 Terryville Road Port Jefferson Station NY 11776

I, ________________________________, have viewed a copy of this office’s Notice of Privacy Practices.

Date: ________________

Patient Signature (Parent/Guardian for minor child under 18)