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PATIENT REGISTRATIONPatient’s Name:(First)(Middle Initial)(Last)Address: Address 2:City: State: Zip:Home Phone: Work Phone: Ext: Cellular: Pager:Patient’s Sex: MaleFemaleMarital Status: MarriedSingleDivorcedSeparatedWidowedPatient’s Birth date:Social Security Number:If patient is over age 18 and a student, student status: Full timePart time Name of school and location:I would like to receive appointment reminders via e-mail: yes or no Email:Responsible Party (if someone other than the patient is responsible for the bill)Responsible Party’s Name:(First)(Middle Initial)(Last)Address: Address 2:City: State: Zip:Home Phone: Work Phone: Ext: Cellular: Pager:Responsible Party’s Birth date:Responsible Party is also a Policy Holder for PatientSocial Security Number:Primary Insurance HolderSecondary Policy HolderPrimary Insurance InformationName of Insured:Relationship to patient: SelfSpouseParent OtherInsured Social Security or Member Identification Number (if not SS #): Insured DOB:Employer:Insurance Company: Telephone:Address: Address 2:City, State, Zip:Secondary Insurance InformationName of Insured:Relationship to patient: SelfSpouseParent OtherInsured Social Security or Member Identification Number (if not SS #): Insured DOB:Employer:Insurance Company: Telephone:Address: Address 2:City, State, Zip:In case of emergency is there someone we may contactTelephone # Relationship to youAfter completing the front portion of this form, please review and sign our financial policy on the back.

MEDICAL HISTORYAlthough dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you mayhave, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering thefollowing questions.Are you under a physician's care now? 0 Yes 0 No If yes, please explain:Have you ever been hospitalized or had a major operation?0 Yes 0 No If yes, please explain:Have you ever had a serious head or neck injury? 0 Yes 0 No If yes, please explain:Are you taking any medications, pills, or drugs? 0 Yes 0 No If yes, please explain:Do you take, or have you taken, Phen-Fen or Redux? 0 Yes 0 NoHave you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? u Yes NoAre you on a special diet? 0 Yes 0 NoDo you use tobacco? Yes 0 NoDo you use controlled substances? Yes 0 NoPregnant/Trying to get pregnant? 0 Yes NoTaking oral contraceptives? 0 Yes 0 NoNursing? 0 Yes 0 NoAre you allergic to any of the following? Aspirin Other Penicillin Codeine Local Anesthetics AcrylicMetal Latex Sulfa drugsIf yes, please explain:Do you have, or have you had, any of the following?AIDS/HIV PositiveAlzheimer's cial Heart ValveArtificial JointAsthmaBlood DiseaseBlood Transfusion0 Yes 0 No0 Yes 0 No0 Yes 0 No0 Yes 0 No0 Yes 0 No Yes No Yes No Yes No Yes No0 Yes 0 No0 Yes 0 NoBreathing Problem0 Yes 0 NoBruise Easily0 Yes 0 NoCancer0 Yes 0 NoChemotherapy0 Yes 0 NoChest Pains0 Yes 0 NoCold Sores/Fever Blisters 0 Yes 0 NoCongenital Heart Disorder Yes 0 NoConvulsions0 Yes 0 NoCortisone Medicine0 YesDiabetes0 YesDrug Addiction0 YesEasily Winded0 YesEmphysema0 YesEpilepsy or Seizures0 YesExcessive Bleeding0 YesExcessive Thirst0 YesFainting Spells/Dizziness YesFrequent Cough0 YesFrequent Diarrhea0 YesFrequent Headaches0 YesGenital Herpes0 YesGlaucoma0 YesHay Fever0 YesHeart Attack/Failure0 YesHeart Murmur0 YesHeart Pacemaker0 YesHeart Trouble/Disease 0 Yes No No No No No No No No No0 No0 No0 No0 No0 No0 No No No No NoHemophilia0 Yes 0 NoHepatitis A0 Yes 0 NoHepatitis B or C0 Yes 0 NoHerpes0 Yes 0 NoHigh Blood Pressure 0 Yes 0 NoHigh Cholesterol Yes NoHives or Rash Yes NoHypoglycemia Yes 0 NoIrregular Heartbeat 0 Yes 0 NoKidney Problems0 Yes 0 NoLeukemia0 Yes 0 NoLiver Disease0 Yes 0 NoLow Blood Pressure 0 Yes 0 No0 Yes 0 NoLung DiseaseMitral Valve Prolapse 0 Yes 0 NoOsteoporosis0 Yes 0 NoPain in Jaw Joints0 Yes 0 NoParathyroid Disease 0 Yes 0 NoPsychiatric Care0 Yes 0 NoRadiation Treatments0 Yes 0 NoRecent Weight Loss0 Yes 0 NoRenal Dialysis0 Yes 0 NoRheumatic Fever0 Yes 0 NoRheumatism0 Yes NoScarlet Fever Yes NoShingles Yes NoSickle Cell Disease Yes NoSinus Trouble0 Yes 0 NoSpina Bifida0 Yes 0 NoStomach/Intestinal Disease 0 Yes 0 NoStroke0 Yes 0 NoSwelling of Limbs0 Yes 0 NoThyroid Disease0 Yes 0 NoTonsillitis0 Yes 0 NoTuberculosis0 Yes 0 NoTumors or Growths0 Yes 0 No0 Yes 0 NoUlcersVenereal Disease0 Yes 0 NoYellow Jaundice0 Yes 0 NoHave you ever had any serious illness not listed above? 0 Yes 0 NoComments:To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.SIGNATURE OF PATIENT, PARENT, or GUARDIANDATE

Wol (onProviding Family and.Cetmetic uentistry with Personal CareDental Health QuestionsCorrect answers to the following questions will allow your dentist to treat you on a moreindividual basis, providing the care appropriate for your particular needs. Circle, yes or no,whichever applies, in response to the following questions. Your answers are for our records onlyand will be considered confidential.Date of Birth:Patient's Name:How did you hear about our practice? Friend or Family Member (name)Insurance Directory Advertisement Other1. Are you having any discomfort at this time?2. Date of your last dental visit3. Have you been treated for periodontal disease?4. Do you have or have you ever had any of the following?Bleeding, sore gumsUnpleasant taste/bad breathBurning tongue/lipsFrequent blisters lips/mouthSwelling/lumps in mouthOrtho treatments (braces)Biting cheeks/lipsClicking/popping jawDifficulty opening or closing jawLoose teethSensitive to hot or coldSensitive to sweetsFood impactionGrinding/clenchingShifting or change in bite5. Do you use the following?Toothbrushyes noDental flossyes noHow Often?How Often?yesnoyesnoyesyesyesyes ononononono

NOTICE OF PRIVACY PRACTICESPATIENT CONSENT FORMI understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I havecertain rights to privacy regarding my protected health information. I understand that this information canand will be used to: Conduct, plan and direct my medical treatment and follow-up among the multiple healthcareproviders who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications.I have been informed by you of your Notice of Privacy Practices containing a complete description of theuses and disclosures of my health information. I have been given the right to review such Notice ofPrivacy Practices from time to time and that I contact this organization at any time at the below address toobtain a current copy of the Notice of Privacy Practices.I understand that I may request in writing that you restrict how my private information is used or disclosedto carry out treatment, payment or health care operations. I also understand you are not required toagree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.I understand that I may revoke this consent in writing at any time, except to the extent that you havetaken action relying on this consent.Patient Name: Date:Signature: Relationship to Patient:PERMISSION TO LEAVE A MESSAGEDue to HIPAA regulations, we are not permitted to leave a message regarding your appointments withoutprior permission from you. You need to give us verbal permission which only then we can document inyour account. If you do not provide permission then you will receive a phone call requesting that youcontact Dr. Wolken's office.This permission will only be used to leave messages for appointments, no other message will be left norany information given to anyone without written permission from you.Name: Date:Signature:

WOLKEN DENTAL FINANCIAL POLICYIt is the patient’s responsibility to provide our office with the correct billing and insurance information. This includes name, date ofbirth, social security number, place of employment, name of employee carrying insurance; as well as the name and address of theinsurance company. Failure to provide the correct information may result in insurance denial and the patient assuming fullresponsibility for the balance.We have several financial options available for your convenience to enable you to receive the proper dental care. We accept all majorcredit cards, debit cards, checks and cash. We offer the Care Credit Card as our extended payment option for those who qualify.Insurance and Insurance CollectionWe participate in many dental plans and we will be happy to submit your insurance claims at no charge, however, we are notresponsible for the decisions made by your insurance company regarding payment or non-payment on your claim. Dental insurance isa contract between the patient and the insurance carrier, not between the carrier and the dentist. Knowing your insurance plan benefitsis your responsibility. You may contact your Human Resources/Personnel Department or insurance carrier to verify your dentalbenefits.A request to your insurance company to pre-authorize dental treatment will be done before treatment is started. The pre-authorizationwill give an overview of the projected costs allowed by your particular insurance plan. Any treatment not pre-authorized by yourinsurance company will necessitate payment in full for treatment by the patient. Payment for unauthorized treatment must be paidwhen treatment is started. Any unpaid balance is due when treatment is completed.The estimated portion not covered by your insurance is due at the time the treatment is performed. Please be aware that we are onlycapable of estimating your portion and we will collect at the time services are rendered. Once the insurance company has paid theirportion of the charges, if there is a balance remaining, we will mail you a statement.Patients under the age of 18The adult accompanying a minor and the parents (or guardian) of the minor are responsible for the full payment. For unaccompaniedminors, non-emergency treatment will be denied unless the charges have been pre-authorized to an approved credit plan, credit card orpayment by cash or check at the time of service.Rebilling FeesWe reserve the right to assess your account with a finance charge of 1.5% for any outstanding balance over 30 days old.Broken or Missed AppointmentsWe ask that patients make every effort not to change reserved dental appointments. If you find that you must change yourappointment, we require a minimum of 24 hour notice so that we may accommodate another patient. A charge will be applied tobroken and missed appointments without advanced notification.I have read the Financial Policy and I understand and agree to the terms. I acknowledge that payment is due at the time oftreatment, unless other arrangements are made in advance. I agree that parents, guardians or personal representatives areresponsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for allcharges for services or items provided to me, to my minor/child, or to the patient for whom I have legal responsibility. Iunderstand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of allcharges.X DateSignature of Patient or Responsible PartyX DateSignature of Co-Responsible Party (when applicable)

WOLKEN DENTAL FINANCIAL POLICY It is the patient's responsibility to provide our office with the correct billing and insurance information. This includes name, date of birth, social security number, place of employment, name of employee carrying insurance; as well as the name and address of the insurance company.