Name: _________________________________ Date:__________________________________

“Getting to know you and your mouth” Are you nervous about dental treatment?______If so, why?_______________________________ Is there anything about your mouth that concerns you?____If so, what?_____________________ What type of toothbrush is used? Soft____ Medium___Hard___How often?__________ Do you use dental floss?____How often?_________Do you use toothpicks__________ Do you have any bumps or sores in the mouth?____If so, where?___________________ Have you ever been told that you have gingivitis or gum disease?____If so, when?______ Do you

generally have an unpleasant breath or taste?____________________________________ Do you smoke?____If so, how long?______How often?__________How much?_____ Are there any teeth that are sensitive to the following? Cold?___Hot?___Sweets?___Air?___

Pressure?_____Chewing?_____If so, where?____________________________________ Do you have any removable appliances in your mouth?____If so, how long?___________

Is it comfortable?_____Do you have a spare in case of loss or breakage?______________ Do you chew ice, corn nuts, popcorn kernels or any other extremely hard foods?________ Do you clench your teeth during the day?____During the night?____How often?______ Do you have frequent headaches?____Sore jaw muscles?____If so, how often?________ Have you ever experienced “TMJ” problems such as popping, clicking, or grinding of the jaw

joint while opening and closing the mouth?____________________________ Would you like your teeth whitened?____ Would you like any dark fillings or crowns changed to

the modern white fillings or all porcelain crowns?____If so, where?______________ Are there any crooked teeth that you would like straightened?____If so, where?____ Is there anything in your mouth or smile you would like changed?__________________

STOP BANG

Screening For: Obstructive Sleep Apnea (OSA) Using a Home Sleep Test Device (HST)

Answer the following STOP-BANG questions to find out if you are at risk for OSA STOP (Yes to >2) S (Snore) Have you been told that you snore? Yes / No T (Tired) Are you often tired during the day? Yes / No O (Obstruction) Do you know if you stop breathing or has anyone Yes / No Witnessed you stop breathing while you are asleep P (Pressure) Do you have high blood pressure or on medication Yes / No To control high blood pressure BANG (YES to >3) B (BMI) Is your Body Mass Index greater than 30? Yes / No

A (Age) Are you 50 years or older? Yes / No

N (Neck) Are you a male with a neck circumference >17” Yes / No Or a female with a circumference >16”? G (Gender) Are you a male? Yes / No

5478 Tomah DriveTafolla & Rikli Family Dentistry Colorado Springs, CO 80918Family Dentistry to Include Orthodontics (719) 598-6680

FACTS YOU SHOULD KNOW ABOUTDENTAL INSURANCE

If you have any questions regarding your insurance, you should contact your insurance company regarding the details of the plan it is conducting on your behalf. We are happy to help you submit your claims and we will try to get the maximum benefits for you that your plan provides. Please remember that your insurance is a contract between you and your insurance company. Our office makes every possible effort to provide you with an accurate estimate of insurance benefits. There are times when this is not possible because of insurance companies varying fees and benefits.

ANY DIFFERENCES BETWEEN THE ESTIMATED INSURANCE PAYMENTS AND ACTUAL PAYMENTS MADE BY THE INSURANCE COMPANY ARE THE PATIENT’S RESPONSIBLITY.

I UNDERSTAND AND AGREE WITH THE ABOVE STATEMENTS.

ACCOUNT HOLDER’S NAME_____________________________ DATE_____________________________

PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

➢ Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

➢ Obtaining payment from third party payers (e.g. my insurance company);

➢ The day-to-day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signed this______day of____________, 20____

Print Patient Name:______________________________

Relationship to Patient:___________________________

Signature:______________________________________

Practice Name: Tafolla & Rikli Family Dentistry

Address: 5478 Tomah Drive

City/State/Zip: Colorado Springs, CO 80918