1 PATI E NT I N FO RMATION 2 I N S U RANCE I N FO RMATION

Patient Name:

Last First MI

Date: Male Female Married Single ChildBirth Date: Home #: Work #:

Email Address: Address: Street Apt. #

City ZIP Code

RESPONSIBLE PARTY INFORMATION

same as above Name:

Last First MI

Male Female Married SingleBirth Date:

EMPLOYMENT INFORMATION

The following is for: the patient the person responsible for paymentEmployer Name: Occupation:

Cell #: Best time to call:

Preferred Name:

Home #: Work #:

Address: Street Apt. #

City ZIP Code

Cell #: Best time to call:

Address: Street Apt. #

City ZIP Code

Subscriber’s Name:

Subscriber’s Birth Date: Relationship to Patient: Insurance Company Name:

Group #: Is there any additional dental insurance? Yes No

ASSIGNMENT and RELEASE

xPatient or Responsible Party Signature Date

REFERRAL INFORMATION

Passing By Newspaper Relative Another Patient Direct Mail Work Friend Insurance Plan Guide Other

Name of Person Referring you to us:

Dental insurance is a contract between the patient and the insurance carrier and not between the insurance carrier and PacificSmiles. As a courtesy, PacificSmiles will file the insurance claim on your behalf. In the event that the insurance pays less than the actual bill for services, the patient is responsible to pay any co-payments, deductibles or unpaid balances.

Subscriber’s SS# or ID#:

Insurance Phone #:

Subscriber’s Name:

Subscriber’s Birth Date: Relationship to Patient: Insurance Company Name:

Group #:

Subscriber’s SS# or ID#:

Insurance Phone #:

Whom may we thank for referring you to Pacific Smiles?

3 I N C A S E OF E M E RG E NCY

Home #:

Name:

Relationship: Cell #:

Work #: Ext.

4 DE NTAL I NTE RVI EW

Name of Previous Dentist and Location:

How long has it been since your last thorough exam?

How long has it been since your last complete series/full mouth x-rays of your teeth?

What prompted you to seek dental care at this time?

Yes No

Yes No If yes, describe:

Are you fearful? Yes No Rate your fear level (1-10):

Did you ever have any bad experiences or reason for the fear? (Explain):

Yes No

Yes No

Special time frames?

What quality of dentistry do you want us to recommend? “Just Patch It” Average Ideal/The Best

Place a mark on “yes” or “no” to indicate if you have had any of the following: Yes No Clenching Teeth

Clicking or Popping Jaw Joints

Fingernail Biting

Grinding Teeth

Headaches

Jaw Pain or Tiredness

Lip or Cheek Biting

Orthodontic Treatment

Pain Around Ear

Ringing in the Ears

Sensitivity to Biting

Sensitivity to Hot, Cold, Sweets

Vertigo

Yes No

Do you have an unpleasant taste or odor in your mouth?

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Gums Swollen or Tender

Periodontal Treatment / Gum Treatment

Chew on One Side of Mouth

Loose Teeth

Broken Fillings

Sores or Growths in Your Mouth

Do you feel pain to any of your teeth?

Ear Congestion/”Blocked Feeling” in Ears

If any of your mercury/silver fillings need replacementwould you prefer to have a more natural tooth-colored restoration instead?

Are you dissatisfied with the way your teeth look? (For example: color, shape, spaces, etc.)

Do you know we provide in-office financing?

Did you have any finance concerns?

If yes, what are your financial concerns?

Do your gums bleed while brushing or flossing?

Have you had a bite plate or night guard made?

Yes No Are you missing any teeth?If yes, would you like options to replace them? Yes No

5 H EALTH H ISTO RYPhysician’s Name:

Date of Last Visit:

Aids/HIV ANEMIAArthritis, Rheumatism

AsthmaBack ProblemsBleeding abnormally, with... extractions or surgeryBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough, persistent or bloody

*DiabetesEmphysemaEpilepsy

Do you take medication for osteoporosis? (ex. Fosomax)If yes, what and how often?

Do you use antidepressants or sleeping pills? If yes, list name(s)

Have you ever been hospitalized for any surgical operations or serious illness within the last 5 years? If yes, please explain

Are you on any blood thinners, including aspirin? If yes, what?

MEDICATIONSList any medications you are currently taking and the correlating diagnosis:

Pharmacy Name: Phone:

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicineschange, I shall inform the dentist and the team at the next appointment without fail.

Patient or Responsible Party Signature: x Date:

Fainting or Dizziness*Glaucoma

*Heart MurmurHeart ProblemsHepatitis TypeHerpesHigh Blood PressureJaundiceJaw PainJoint ReplacementKidney DiseaseLiver Disease Low Blood PressureMitral Valve ProlapseNervous Problems

*PacemakerPsychiatric CareRadiation TreatmentRespiratory Disease

Scarlet FeverShortness of Breath

*Sinus TroubleSkin RashSpecial DietStrokeSwollen Feet or AnklesSwollen Neck GlandsThyroid ProblemsTonsillitisTuberculosisTumor or Growth on... Head or NeckUlcerVenereal DiseaseOthers

Comments:

Yes No

Yes No

Yes No

Yes No

WOMENAre you pregnant?If yes, when is your due date? Taking birth control pills?

Are you taking hormones?

ALLERGIES No Allergies Local Anesthetic

Aspirin Penicillin

Barbiturates (sleeping pills) Sulfa

Codeine Latex

Iodine Other

Yes No

*Artificial Heart Valves*Artificial Joints

*Rheumatic Fever

*Osteoporosis

Have you had a history of previous sinus infections orcongestion?

6 CON S E NT AN D R E LEA S E S

Patient or Responsible Party Signature: x Date:

Please INITIAL and SIGN below:

I hereby authorize Dr. Fred Kim and/or his team to take photographs of my face, jaw and teeth. I understand that the photographs will be used as a record of my care and treatment and may be used for educational and marketing purposes.

I must provide with 48 business hours advance notice for any cancellations of any of my appointments in order to avoid the imposition of cancellation fees; which are determined by the length and type of service being rendered at the scheduled visit. Such cancellation fees are non-refundable.

I certify that I have read and understand the above information to the best of my knowledge. The questions on both sides have been accurately answered, and I understand that providing incorrect information can be dangerous to my health.

I understand that dental insurance is a contract between the patient and the insurance carrier and not between the

insurance carrier and PacificSmiles. As a courtesy, PacificSmiles will file the insurance claim on your behalf.

In the event that the insurance pays less than the actual bill for services, the patient is responsible to pay any

co-payments, deductibles or unpaid balances.

I hereby authorize Pacific Smiles and Dr. Kim to administer such medicine and perform such diagnostic andtherapeutic procedures as may be necessary for proper dental care.