Thank you Jor selecting our dental healthcare team!We will strive to provide you with the best possible dental care.

To help us meet all your dental healthcare needs, please Jill out this Jormcompletely in ink. If you have any questions or need assistance, please ask us -

we will be happy to help.

Patient # _SS#/SIN _

Patient Information (CONFIDENTIAL) Date _Name Birthdate Home Phone

------- State! ---:Z=ip,-)/,-----Address City Provo P C _Email Cell Phone _

Check Appropriate Box: 0 Minor 0 Single 0 Married 0 Divorced 0 Widowed 0 SeparatedState! Full Part

If Student, Name oj School/College City Provo 0 Time 0 Time

Patient or Parent/Guardian's Employer Work Phone_-:=;-;--;- _State/ Zip'/Address City Prov. PC _

Spouse or Parent/Guardian's Name Employer Work Phone _Whom may we thank Jor reJerringyou? _

Person to contact in case oj emergency Phone _

Responsible Party RelationshipName oJPmon Responsible Jor this Account to Patient _

Address Home Phone _Email Cell Phone _

Driver's License # Birthdate Financial Institution _Employer Work Phone SS#/SIN _

Is this person currently a patient in our office? 0 Yes 0 No

Foryour convenience, we offer the follOWingmethods of payment. Please check the option you prefer Payment in fu.ll at each appointment.

o Cash 0 Personal Check Credit Card 0 VISA 0 MasterCard 0 Iwish to discuss the office'S payment policy.

Insurance InformationRelationship

Name oj Insured to Patient _

Birthdate SS#/SIN Date Employed _

Name oj Employer Union or Local # Work Phone _State! Zip/

Address oJEmployer City Provo PC _

Insurance Company Group # Policy/ID # _=---;-- _State! Zip!

Ins. Co. Address City Provo P C _

How much is your deductible? How much have you used? Max. annual benefit. _

DO YOU HAVE ANY ADDITIONAL INSURANCE? DYes DNa IF YES, COMPLETE THE FOLLOWING:

RelationshipName oJ Insured to Patient _

Birthdate SS#/SIN Date Employed. _

Name oJ Employer Union or Local# Work Phone_::c:--,--- _State/ Zip/

Address oJ Employer City Provo PC _

Insurance Company Group # Policy/ID #_=---;------State/ Zip/

Ins. Co. Address City Provo PC _

How much is your deductible? How much have you used? Max. annual benefit _Over Please

Patient Medical HistoryPhysician _ Office Phone Date of Last Exam _

1. Are you under medical treatment now? .2. Have you ever been hospitalized for any

surgical operation or serious illness within the last 5years? ..If yes, please explain _

3. Are you taking any medication(s)including non-prescription medicine? .If yes, what medication(s) are you taking? _

4. Haveyou ever taken Fen-Phen/Redux? .5. Have you ever taken Fosamax, Boniva, Actonel or any cancer

medications containing bisphosphonatesl .

6. Haveyou taken Viagra, Revatio, Cialis or Levitrain the last 24 hours? .

7. Do you use tobacco1 .

8. Do you use controlled substances?......... . .9. Do you have or have you had any of the following?

Yes NoD DD D

D D

D DD DD DD DD D

10. Are you wearing contact lenses I..11. Areyou allergicto or haveyou hadany reactionsto thefollowing?

Local Anesthetics (e.g. Novocaui) .Penicillin or any other AntibioticsSulfa Drugs. .. .Barbiturates ...Sedatives ...Iodine ..Aspirin.. . .Any Metals (e.g. nickel, mercury, etc.)Latex Rubber .Other (please list) __ -,;---,_--;---,- _

12. Do you havea perSistentcoughor throat clearingnotassociatedwith a known illnessOastingmore than 3 weeks)? ..

13. Women Only:a) Are you pregnant or think you may be pregnant?.b) Are you nursing? .c) Are you taking oral contraceptives?

Yes No Yes NoHigh Blood Pressure D D Heart Disease D DHeart Attack. ........................ D D Cardiac Pacemaker D DRheumatic Fever ..... D D Heart Murmur D DSwoilen Ankles D D Angina ... D DFainting / Seizures D D Frequently Tired D DAsthma .. D D Anemia. .... ................ D DLow Blood Pressure .... D D Emphysema. D DEpilepsy / Convulsions D D Cancer .... D DLeukemia .......... D D Arthritis D DDiabetes. ....... ............ D D Joint Replacement or Implant .. D DKidney Diseases ..................... D D Hepatitis / Jaundice D DAlDS or HIV Infection D D Sexually Transmitted Disease D DThyroid Problem .. D D Stomach Troubles / Ulcers D D

Patient Dental HistoryName of Previous Dentist and Location

Chest Pains .Easily Winded ..Strolu .Hay Fever/ AllergiesTuberculosis... .. .Radiation TherapyGlaucoma .Recent Weight LossLiver Disease ..Heart Trouble .Respiratory ProblemsMitral Valve ProlapseOther _

Yes NoD D

D DD DD DD DD DD DD DD DD D

D D

D DD DD DYes NoD DD DD DD DD DD DD DD DD DD DD DD DD D

______________________ Date of Last Exam _

1. Do your gums bleed while brushing orflossing? .....2. Are your teeth sensitive to hot or cold liquidsljoods? .3. Are your teeth sensitive to sweet or sour liquidsljoods?4. Doyoufeelpain to any ofyour teeth I .

5. Do you have any sores or lumps in or near your mouth? .6. Have you had any head, neck orjaw injuries? .7. Have you ever experienced any of thefollOwing

problems in your jaw?Clicking ...Pain voint, ear;side offace) ..Difficulty in opening or closingDifficulty in chewing

Authorization and Release

YesDDDDDD

DDDD

NoDDDDDD

8. Do you havefrequent headaches 1 .

9. Do you clench or grind your teeth? .10. Do you bite your lips or cheeksfrequently?11. Have you ever had any difficult extractions

in the past? .12. Have you ever had any prolonged bleeding

following extractions? .. .13. Have you had any orthodontic treatment?14. Do you wear dentures or partials 7.....

If yes, date of placement. _15. Have you ever received oral hygiene instructions

regarding the care of your teeth and gums? ..16. Do you likeyour smile? ..

YesDDD

NoDDD

DDDD

D D

DDD

DDD

DD

DD

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered.I understand that proViding incorrect information can be dangerous to my health. I authorize the dentist to release any information including thediagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payorsand/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefitsotherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsiblefor payment of all services rendered on my behalf or my dependents.XSignature of patient (or parent/guardian if minor) Date

Doctor's Comments

Signature DatePATTERSON OFFICE SUPPLIES 1.800.637.1140 051-1014/16306

Dawn Gayken, D.D.S.25250 Borough Park, Suite 107The Woodlands, TX 77380

(281) 367-2767 .

Insurance Consignment and Loan Agreement

Nrune: _

Insured: Insurance Company: _

I authorize dawn Gayken, D.D.S., PLLC and Gayken Dental Group to submit insurance claims on mybehalf

I understand and agree with the following:

1. Dr. Gayken is not an agent of my insurance company

2. Dr. Gayken only files my claims, as a courtesy and does not guarantee coverage or payment.The estimates on her treatment plans are just an opinion based on very limited information,

3. After an E. O.B. (estimate of benefits ) is received, I will promptly pay any portion still leftOWIng.

4. In the event that the insurance holds the claim for an extended period of time (more that 70 daysfrom the date it was submitted). I will pay for the treatment and be reimbursed for what myinsurance pays.

5. If the claim is denied improperly, I will pay for my treatment and look to the insurance companyor my employer's human resource department for reimbursements.

6. I understand that the payment for my treatment is ultimately and solely my responsibility.

7. If a second claim needs to be filed because I disclosed incorrect insurance information, I will payfor my treatment and have the any fee to be paid by the second claim directly to me.

8. Balances past due are subject to a billing charge of$1.17 plus 18% interest compoundedmonthly. Balance over 90 days are subject to all legal means of collecting a debt.

9. Dr. Gayken can accelerate your entire account balance if any portion of your account is 60 dayspast due or more.

Patient's Guardian's Signature: _Patient, Parent ofLegal Guardian

Date _

If signed by patient representative, state relationship to patient: _

Dawn Gayken, D.D.S., PLLC25250 Borough Park, Suite # 1071 The Woodlands TX, 77380 , 281-367-2767

Written Financial Policy

Thank you for choosing Dawn Gayken, D.D.S., PLLC. Our primary mission is to deliver the best and mostcomprehensive dental care available. An important part of the mission is making the cost of optimal care aseasy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

- Visa. Mastercard. Discover, Cash, Check

- NO INTEREST1 Payment Plans2 from CareCredit

a Allow you to pay over time with NO INTEREST'

o Convenient, low monthly payment plans2 also available

a No annual fees or pre-payment penalties

Please note:

Dawn Gayken, D.D.S., PLLC requires payment prior to the beginning of your treatment. If you choose todiscontinue care before treatment is complete. you will receive a refund less the cost of care received.

For larger, more comprehensive treatment plans of $1000 or more, a deposit on a case by case basis isrequired to secure your initial treatment appointment.

For patients with dental insurance we are hapPl to work with your carrier to maximize your benefit and directlybill them for reimbursement for your treatment.

A fee of $150.00 for Doctor, and a fee of $35.00 for Hygienist is charged for patients who miss orcancel an appointment without 48·hour notice.

Dawn Gayken, D.D.S., PLLC charges $35 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentiStry you want andneed.

Patient. Parent or Guardian Signature Date

Patient Name (Please Print)

11f paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.2Subject to credit approval3However. if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your. treatment fees and collection of your benefits directly from your insurance carrier.

Dawn Gayken, D.D.S.25250 Borough Park, Suite 107The Woodlands. TX 77380

(281) 367-2767

CONSENT FORM

I give this prnctice' s my consent to use or disclose my protected health informatioalo carzy out my treatment, to obtainpayment from Insurance companies, and for health care operations like quality reviews.

Ihave been informed that I may review the practice's Notice of Privacy Practices (for a more complete description of usesand disclosures) before signing this consent

I understand that this practice has the right to change their privacy practices and that J may obtain any revised notices at thepractice,

I understand that I have the right to request 3 restriction of bow my protected health information is used. However, I alsounderstand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, theymust follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing. except for information alreadyused DC disclosed.

Patient's Gu.an:Iian's Signature: _Patient, Parent of Legal Guardian

Date _

If signed by patient representative, state relationship to patient: _

-'-,

PATIENT CONSENTFOR

USE AND DISCLOSURE OF HEALTH INFORMATION

Dawn Gayken, DDS25250 Borough Park, Ste. 107The Woodlands, TX 77380

P~N~: ~ _

Address: _

Te~: _ E~t _

HIPAA requires that we obtain your consent to use and disclose your protected health information for the purposes ofcarrying out t1eatment, obtaining payments, and carrying on healthcare operations for your care.

By signing this consent form yoo will have acknowtedged that you have read our Notice of Privacy Practices.

You have the right to revoke this Consent by submitting your revocation to us in writing. My action we took prior to yourrevocation will not be affected. We may choose to discontinue your treatment if you revoke your consent for us to use anddisclose your health information for ~ reasons stated above.

I, , (print your name here) have read the Notice of PrivacyPractices and consent to your use and disclosure of my protected health information to carry out treatment, paymentactivities and heath care operations.

Signature: Date: _

Personal Representative's Name: _Relationship to Patient _

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, andhealthcare operations.

Iunderstand that any action you took prior to my revocation will not be affected. As a result of my revocation, you may electto discontinue treating me.

Signature: _ Date: _

This document is not a substitution for legal advice.

Adjunctive Oral Cancer Screening Acceptance FormComplete each time the examination is performed and place in the patient's file

Our practice continually strives to provide important enhancements in oral health care for our patients.We are concerned about oral cancer and look for it in all at risk patients.

One person dies every hour from oral cancer in the United States.

Late detection of oral cancer is the primary reason that mortality rates are so dismal. As with most other cancers,age is the primary risk factor for oral cancer. Though tobacco use is a major predisposing risk factor, 25% oforal cancer victims have no lifestyle risk factors.

Oral Cancer Risk profileIncreased risk

• Patients age 40 and older (95% of all cases)• 18-39 years of age combined with any of the following:

• Tobacco use• Chronic alcohol consumption• Oral HPV infection

Highest risk• Patients age 65 and older with lifestyle risk factors• Patients with history of oral cancer

• 25% of oral cancers occur in people who don't smoke and have no other risk factors.

We find that using ViziLite Plus along with a visual oral cancer examination improves our ability to identifysuspicious areas that may have been missed during the conventional examination. Early detection ofprecancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancer and possiblysave your life. ViziLite Plus is a painless exam that gives us a better chance to find any oral abnormalitiesyou may have at an early stage.

Dental insurance might not cover the ViziLite Plus exam. However, this office is happy to verify yourcoverage for you and will also provide you with a medical insurance form for YbQo use to file thisprocedure with your medical insurance. The fee for this enhanced examination is $ . ..~

Yes. I authorize the clinician to perform the ViziLite Plus exam along with the standard oral cancerexamination. I accept financial responsibility for this enhanced examination.

Print name: -----------------------------------------------------Signature: Date: ~

No. I would prefer not to have the ViziLite Plus exam at this time.

Printname: _

Signature: Date: _

111'"11111111111 11"11"" 11111 11111111ZILA-215-2008-1 650602 0409