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WelcomeThank you for selecting us.To help us meet all your healthcare needs, please fill out this form completely in ink. If you haveany questions or need assistance, please ask us and we will be happy to help.Patient 1nformation(Confidential)Patient NumberNameDateSS# / SINBirthdateHome PhoneAddressCityState/Prov.EmailZip/P.C.Cell Phoneo MinorCheck Appropriate Box:o Singleo Marriedo Separatedo DivorcedIf Student, Name of School / CollegeState/ProvoPatient or Parent / Guardian's EmployerWork PhoneBusiness AddressCitySpouse or Parent / Guardian's Name0 Full TimePerson to Contact in Case of Emergency0 Part TimeState/Prov.Employero WidowedZip/P.C.Work PhonePhoneResponsible PartyName of Person Responsible for this AccountRelationship to PatientAddressHome PhoneEmailCell PhoneDriver's License #BirthdateFinancial InstitutionEmployerWork PhoneSS# / SINIs this Person Currently a Patient in our Office?DYesFor your convenience,ment.0 Nowe offer the following methods of payment. Please check the option you prefer. Payment in full at each appoint-o Personal·0 CashCheckCredit Cardo VISAo MasterCardo I wishto discuss the office's payment policy.Referral InformationWhom may we thank for referring you to our practice?o ShopperO Newspaper0 Telephone BookName of Person or office referring you to our practice:WPC 26·760'Walker Printing'1-800-423-00030 PatientO Friend0 Insurance Company0 Work0 Other

Patient Medical HistoryPhysicianOfficePhoneYesNo1.Are you under medical treatment now?002.Have you ever been hospitalized for any surgicaloperation or serious illness within the last 5 years?0000Date of Last Exam8.If yes, please explainAre you taking any medication(s)non-prescription medicine?3.If yes, what medication(s)includingare you taking?4.Do you use tobacco?005.Do you use controlled substances?006.Are you wearing contact lenses?007.Do you have or have had any of the following?High Blood PressureHeart AttackRheumatic FeverSwollen AnklesFainting/SeizuresAsthmaLow Blood PressureEpilepsy/ConvulsionsLeukemiaDiabetesKidney DiseasesAIDS or HIV InfectionThyroid ProblemHeart DiseaseYesNo00000000000000000000000000009.YesNoAre you allergic to or have you had any reactionsto the following:Local Anesthetics (e.g. Novocaine)Penicillin or any other antibioticsSulfa DrugsBarbituratesSedativesIodineAspirinAny Metals (e.g. nickel, mercury, etc.)Latex RubberOther00000000000000000000Do you have a persistent cough or throat clearing notassociated with a known illness (lasting more than 3 o00000000000000000010. Women Only:Are you pregnant or think you may be pregnant?Are you nursing?Are you taking oral contraceptives?Cardiac PacemakerHeart MurmurAnginaFrequently TiredAnemiaEmphysemaCancerArthritisJoint Replacementor ImplantHepatitis/JaundiceSexually TransmittedDiseaseStomach Troubles/UlcersChest PainsEasily WindedYesNo0000000000000000000000000000StrokeHay Fever/AllergiesTuberculosisRadiation TherapyGlaucomaRecent Weight LossLiver DiseaseHeart TroubleRespiratory ProblemsSinus ProblemsExcessive BleedingMitral Valve ProlapseOtherPatient Dental HistoryName of Previous Dentist and Location1.2.3.4.5.6.7.Date of Last ExamDo your gums bleed while brushing or flossing?Are your teeth sensitive to hot or cold liquids/foods?Are your teeth sensitive to sweet or sour liquids/foods?Do you feel pain to any of your teeth?Do you have any sores or lumps in or near your mouth?Have you had any head, neck or jaw injuries?Have you ever experiencedin your jaw?YesNo0000000000008.Do you have frequent headaches?9.Do you clench or grind your teeth?10. Do you bite your lips or cheeks frequently?11. Have you ever had any difficult extractions in thepast?12. Have you ever had any prolonged bleeding followingextractions?any of the following problems0000ClickingPain (joint, ear, side of face)Difficulty in opening or closingDifficulty in chewing13. Have you had any orthodontic treatment?14. Do you wear dentures or partials?0000If yes, date of placement15. Have you ever received oral hygiene instructionsregarding the care of your teeth and gums?16. Do you like your smile?Authorization and ReleaseI certify that I have read and understand the above information to the bestof my knowledge. The above questions have been accurately answered.I understand that providing incorrect information can be dangerous tomy health. I authorize the dentist to release any information including thediagnosis and the records of any treatment or examination rendered to meor my child during the period of such Dental care to third party payors and/orhealth practitioners. I authorize and request my insurance company to paydirectly to the dentist or dental group insurance benefits otherwise payableto me. I understand that my dental insurance carrier may pay less than theactual bill for services. I agree to be responsible for payment of all servicesrendered on my behalf or my dependents.x ---- ---- ------Signature of patient (or parent/guardianif minor)-- -------Docto.,', Com me,",I'--SiqnatureDate

HAWKINSVILLE DENTAL ASSOCIATES, LLCClarence (Rence) F. Cheek, Jr., DMD23 LOVERS LANE ROADHAWKINSVILLE, GA 31036478-783-3390Thank you for selecting us for your dental needs. Our primary mission at our office is todeliver the best and most comprehensive dental care available. An important part of thismission is making the cost of dental care as easy and manageable for our patients aspossible.To assist you with your dental care investment, we provide the following:Payment Options1. Our office accepts cash, check, Visa, MasterCard, Discover, and AmericanExpress.2. A 5% bookkeeping discount is offered for cash or check payment in full fortreatment over 1000 when paid at least 24 hours in advance of appointment.3. You may set up a payment plan through our office, making a down payment at thestart of treatment followed by monthly electronic payments through auto debitwith your checking or savings account.4. CareCredit – patient payment plans that allow you to pay over time withconvenient low minimum monthly payments. “No Interest” or “ExtendedPayment” Plans are offered.5. Partial Payments for multiple-appointment treatments over 1,000 – patient canmake 2 payments, ½ payments on initial day and other ½ on completion date.Insurance1. We will file insurance claims as a courtesy to you. You are responsible for theestimated payment options in full when services are rendered by using one of theabove.2. You should be aware that the insurance agreement is between you and theinsurance company. We will attempt to make a good faith estimate of yourinsurance benefits, but we cannot guarantee your insurance will pay as weestimate it. If the Insurance Company declines to pay its estimated portion, thepatient is responsible for any remainder of the fee.If you have questions, please feel free to talk with my Office Manager, Sherry Reeves.

HAWKINSVILLE DENTAL ASSOCIATES, LLCClarence (Rence) F. Cheek, Jr., DMD23 LOVERS LANE ROADHAWKINSVILLE, GA 31036478-783-3390FINANCIAL AGREEMENTTo Patient, Parent, or Guardian:Payment is expected in full at the time services are rendered. If you have insurance wewill gladly process your claim, but we request that you pay your estimated portion in fullwhen services are rendered. Your insurance is an estimate of payment and any balanceleft will be the responsibility of the patient. We offer several methods of paymentsincluding: CASH, CHECK, CREDIT CARDS, and a DENTAL FEE PLAN (CareCredit). If your account becomes past due and collection procedures are rendered, youwill be responsible for ANY and ALL cost.Signature:Date:

DENTALASSOCIATES.HAWKINSVILLELLCNOTICEOF ORTANONABOUTYOTJTAY BE U9EDAND DISCLOSEDHOWYOUCAil GETACCESSTOTHIS lltlFoRtAnoil.PLEASEREVIEWIT CAREFULLY.THEPRIVACYOF YOI'R HEALTHINFORTATION s IMFORTANTTO US.OUR LEGALDUTYWe are requiredby applicablefederaland statelawto maintainthe privacyof yourhealthinformation.We are alsorequiredto giveyouthis Noticeaboutour privacypractices,our legalduties,and yourrightsconcemingyourhcalthinbrmation. We mustfollowthe pdvacyprac'ticasthat are descdbedin this Noticewhile it is in effect. This Noticetakesefiect(MttUDDfYR),and will remainin efu untilurcreplaceit.We reservethe rightto changeour privacyprac{icesand the terms of this Noticeat any time, providedsuc}rcfiangesare permittedby applicablelaw. We resene the rightto makethe changesin our privacypracticesand the neurterms of our Noticeefieclivefor all heallhinformatlonthat we maintain,includinghealthinformationwe createdorrecelvedbeforewe madethe changes. Beforeuremakea significantcfiangein our privacypractices,we will ctungethis Noticeand makelhe newNoticeavailableuponrequest.You rnay requesta copy of our Notice at any time. For more informationabout our pri\racyprac{ices,or foradditionalcopiesof this Notice,pleasecontactus usingthe informationlistedat the end of this Notice.USESAl{D DISCLOSURESOF HEALTHINFORMANONWe use and disclosehealthinformationeboutyou fortreatment,payment,and heatthcareoperations. For example:Trcetngnt We may use or discloseyour healthinformationto a physicianor other heatthcareproviderprovidingtroatmentto you.Payment We may use and discloseyourhealthinformationto obtainpaymentfor servicecwe provideto you.Healthcarc Operatlonr: We may use and discloseyour health informationin connectionwith our healthcareoperations. Heahhcareoperations include quality assessmentand improvementactivities, reviewing thecompetenceor qualificationsof healthcareprofessionals,evaluatingprac{itionerand provider performance,certification,licensingor ion,activities.Your Authorlza0on: In addition to our use of yor health informationfor treatment, payment or healthcareopenations,you may give us written authorizationto use your health informationor to disdose it to anyonebr anypurpce. lf you give us an authorization,you may revokeit in Miting at any time. Yourrevocationwill not affed anyuse or disclosurespermittedby your authorizationwhile it was in effeci. Unlessyou give us a writlen authodzation,we cannotuse or discloseyourhealthinformationfor any reasonexceptthosedescribedin this Notice.To Your Familyand Frlende: We mustdisdoseyour heahhinformationto you, as deecdbedin the PatientRightcseclionof this Notlce. We may discloseyour healthinbrmationto a familymember,ftiend or other personto theextentnecessaryto helpwith your healthcareor with paymentfor yourhealthcare,but only if you agreethat we maydo so.Peronr Involved In Cao: We may use or disdose health inbrmation to notiff, or assist in the notificationof(includingidentifyingor locating)a familymember,your pemonalrepresentativeor anotherp Fon responsibleforyour care, of your location,your generalcondition,or death. lf you ere present,then priorto use or disclosureofyour health information,urcwill provideyou with an opportunityto obiectto such uses or disclosures. In the eventofyour incapacityor emergencycircumstiances,we will disclosehealthinformationbasedon a determinationusing ourprofessionaljudgmentdisdosingonly healthinformationthat is directlyrelevanlto the person'sinvolvementin yourhealthcare. We will also use our professionaljudgmentand our experiencewith common practiceto makereasonableinferencesof your best interostin allowinga pensonto pick up filled prescriptions,medicalsupplies,xraye,or othersimilarformsof healthinformation.