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1 !W"]FamiIY First Dentistry, 1611 Sands Place SE, Suite 100, Marietta, GA30067 PH: FX: We welcome you as part of our family. Please provide information to assist us with assisting you. Welcome and thank you for coming in to see us. Howdidyouhearaboutus? Patient Information: SSN: OOB: Address: Apt City State Zip Home Phone: Work Phone: Cell Phone: i address: Responsible Party's Information: Full Name: SSN: OOB: Relationship to Patient: Insurance 10: Group No: Address: Apt: City: State: Zip Home Phone: Work Phone: Cell Phone: address: ----~ Company Name: Occupation: Address: City: State: Zip: Work Phone: CeIiPhone: ~ Emergency contact Information: Full Name: Relationship to Patient: Address: Apt: City: State : Zip: Home Phone: Work Phone: Cell Phone: address: Website: e-rnall: info@familyfirstdentistry.net

2 ,.--~~-----= :: , ~-=- -Family First Dentistry, 16i1 Sands Place SE, Suite 100, Marietta, GA Important Notice: Treatment offered for oral health may not be covered by your Insurance. Plaque bacteria threatens your teeth, gums, restorative and cos-metic work; possibly even your life.. Upgrades from your Insurance i.e. restorations, periodontal, orthodontics, prosthodontics fixed and or removal) Implants, bleaching options and cosmetic enhancement (snap on smile) will be discussed during your treatment plan visit. Signature: Date: Consent for treatment: 1. Hereby authorize Doctor or designated staff to take X-Rays, study models, photophrafs, and other diagraphic aids deemed appropriate by Doctor to make a thorough diagnosis of (Name of Patient) dental needs. 2. Upon such diagnosis, I authorize the Doctor to perform all recommended treatment mutually agreed upon me and to employ such assistance as required to provide proper care. 3. I agree the anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. 4. I give consent to the Doctor's or designated staff's use and disclosure of any oral, written electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I t. " understand that only the minimum amount of information necessary to provide quality care will be used to disclosed and that a notice full outlining the protection of my personnel health information is available.«5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that 1.1/2 late charge (18APR) may be added to my account. I required, I also understand a check of my credit history may be made. Patient's Signature: Date: Witness: Parent/Responsible Party's Signature: Relationship to Patient:

3 Medical History Name: Account No. Medical Alert What is the reason for your visit today? Date of Last Dental Visit Last Dental Cleaning Last Full mouth X-Rays What was done at your last dental visit? ---:: -'---"- ~ Previous Dentist's Name Address State Zip Code Telephone How often do you have dental examinations? How often do you brush your teeth? --,-- How often do you floss? Have you ever used or are currently using topical fluoride? What other dental aide do you use? (Implant, toothpick, etc.) Do you have any dental problems now? If yes please describe: Are any of your teeth sensitive? Hot or cold? Sweets? Biting or chewing? Have you noticed any mouth odors or bad tastes? Do you frequently get cold sores, blisters or any other oral lesions? Do your gums bleed or hurt? Have your parents experienced gum disease or tooth loss? Have you noticed any loose teeth or change in your bite? Does food tend to become caught in between your teeth? If yes, where? Do you: Clench or grind your teeth while awake or asleep? -t-e- Bite your lips or cheeks regularly? Hold f~reign objects with your teeth (pencils, pipe, pins, nails, fingernails) Mouth breathe while awake or asleep? have tired jaws, especially in the morning? Snore or have any other sleeping disorders? Smoke/chew tobacco or use other tobacco products? Have you ever had? Orthodontic treatment? Oral Surgery? Periodontal Treatment? Your teeth round or the bite adjusted? A bite plate or mouth guard? A serious injury to the mouth or head? If so, please describe, including cause Have you experienced? Clicking or popping of the jaw? Pain? Difficulty in opening or closing the mouth? Difficulty in chewing on either side of the mouth? Headaches, neck aches or shoulder aches? Sore muscles (neck, shoulders)? Are vou satisfied with your teeth's appearance? Would you like to keep all of your teeth all of your life? Do you feel nervous about having dental treatment? If so, what is your biggest concern? Have you ever had an upsetting dental experience? If yes, please describe: Have you ever been told to take a pre-medication prior to dental treatment? Isthere anything else about having dental treatment that you would like us to know? Physician's Name Phone Have you had any medical care within the past two years? Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?. If yes, please list name and dosage Have you ever taken prescription medications for weight loss (diet pills)? Other If yes, did you take any of the following? Fen-Phen, Pondimen, Redux,

4 If yes to any of the above, did you have a medical exam for heart issues? Have you ever taken bone prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs? Are you aware of having an allergic (or adverse) reaction to any substance or medication? If yes, please specify Have you been a patient in the hospital during the past five years? ----,- Indicate which of the following you have had, or have at present: lcircie if it applies) Heart (Surgery, Disease,Attack) Chest Pain Congenital Heart Disease Heart Murmur High Blood Pressure Mitral Valve Prolapse Artificial Heart Valve/Pacemaker Rheumatic Fever Arthritis/ Rheumatism Cortisone Medicine Swollen Ankles Stroke Diet (Special/Restricted) Artificial Joints (hip, knee, etc.) Kidney Trouble Ulcers Diabetes. Thyroid Problems Glaucoma Contact Lenses Emphysema Chronic Cough Tuberculosis Asthma Hay Fever/Allergy/Hives, Latex Sensitivity SinusTrouble Radiation Therapy/Chemotherapy Tumors Hepatitis ABC Venereal Disease A.I.D.S./H.I.V. Positive Cold sores/fever Blisters Blood Transfusion Hemophilia Sickle Cell Disease Bruise Easily Liver disease/yellow Jaundice Neurological Disorders Epiiepsy or Seizures Fainting or DizzySpells Nervous/Anxious Psychiatrrc/Psychological Care Have you lost or gained more than 10 pounds in the past year? Do you have or have you had any disease, condition or problem not listed? If yes, please list Women: Are you pregnant or think you could be? Nursing? Do you use birth control prescriptions? I understand the above informati6~ is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to askthe respective health care provider or agency, who may release such information to you. I will notify the doctorof c any change in my health or medication. Patient/Guardian Signature Date History Review: Dentist Signature Date

5 .. Family First Dentistry 1611 Sands Place, Suite 100 Marietta, GA Phone: T Fax: Red Flag Policy. Federal law requires all healthcare practices to obtain, verify, and record information that identifies each new patient. FTC 16 CFR Part 681 III. Detecting Red Flags. Policies and procedures should address the detection of Red Flags in connection with the opening of covered accounts and existing covered accounts, such as by: (a) Obtaining identifying information about, and verifying the identity of, a person opening a covered account, for example, using the policies and procedures regarding identification and verification set forth in the Customer identification Program (CIP) rules implementing 31 U.S.C (1) (31 DFR USA Patriotic Act); and (b) Authenticating customers, monitoring transactions, and verifying the validity of change of address request, in the case of existing covered accounts. The following policies are consistent with requirements of the FTC Red Flag Rules and with the USA Patriotic Act on customer/patient identification (CIP). What the means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. The regulations require each business to establish a customer/patient identification process appropriate for the size and type of business. Cosmetic & Family Dentistry will obtain, verify, and record the following information on new patients: Name Insurance 10 Social SecurityITIN Drivers' License # and State Date of Birth Other Photo 10 Address Other supporting documentation if needed If identification is not possible during an emergency situation, you will not be denied medical care. It will be the responsibility of the patient to provide Cosmetic & Family Dentistry appropriate identification as required by Federal law. I certify I am who I claim to be. I have provided documentation supporting claims and my information was verified by Cosmetic & Family Dentistry staff. It will be my responsibility to inform Cosmetic & Family Dentistry of any changes in my personal information upon future visits. Patient Signature: Date:

6 .. FAMILY FIRST DENTISTRY 1611 SANDS PLACE SE, SUITE 100, MARIETTA, GA PHONE: FAX: NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBESHOW HEALTH INFORMATION INFORMATION. ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESSTO THIS PLEASEREVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US OUR LEGAL DUTY: We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and applicable law permits the terms of this notice at any time, PROVIDED SUCH CHANGES. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all -if; health information significant that we maintain, including health information we created or received before we made the changes. Before we make a change in our privacy practices, we will change this notice and make the new notice available upon request. of our notice at any time. information For more information about our privacy practices, or for additional You may request a copy copies of this notice, please contact us using the listed at the end of this notice. USES AND DISCLOSURESOF HEALTH INFORMATION: healthcare operations. Treatment: We use and disclose health information about.vou for treatment, payment, and For example: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. " Payment: We may use and disclose your health information Healthcare Operations: We m'ay use and disclose your health information include quality assessment and improvement practitioner and provider performance, Your Authorization: authorization writing activities, conducting at any time. Your revocation authorization, training programs, accreditation, for treatment, will not affect any use or disclosures permitted we cannot use or disclose your health information or with payment for your healthcare, disclosing only health information Health-Related payment or healthcare operations by your authorization activities. you may give us written you may revoke it in while it was in effect. Unless you give for any reason except those described in this notice. To Your to notify, or assist in the notification of (including identifying or locating) we will provide you with an opportunity we will disclose health information or death. to object to such uses or based on a determination that is directly relevant to the person's involvement using in your healthcare. We will and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, Marketing licensing or credentialing evaluating or another person responsible for your care of your location, your general condition, If you are present, then prior to use or disclosure of your health information, our professional judgment Healthcare operations professionals, but only if you agree that we may do so. disclosures. In the event of your incapacity or emergency circumstances, also use our professional judgment certification, operations. of healthcare to a family, friend or other person to the extent necessary to help with your Persons Involved In Care: We may use or disclose health information a family member, your personal representative with our healthcare for qualificatiorj or to disclose it to anyone for any purpose. if you give us an authorization, Family and Friends: We disclose your health information healthcare in connection reviewing the competence in addition to our use of your health information to use your health information us a written to obtain payment for services we provide to you. medical supplies, x-ravs, or other similar forms of health information. Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information your health information to appropriate authorities when we are required to do so by law. Abuse or Neglect: We may disclose if we reasonable believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information your health or safety or the health or safety of others. to the extent necessary to avert a serious threat to

7 ~~. FAMILY FIRST DENTISTRY 1611 SANDS PLACE SE, SUITE 100, MARlEnA, GA PHONE: FAX: TREATMENT AND BILLING CONSENT FORM INITIAL DIAGNOSTICPROCEDURES: In order to help formulate treatment recommendations diagnostic procedures may be required to be performed such as, medical and dental history, discussion of your dental problems, concerns and desires, x-rays plaster casts of the mouth and teeth, examination of the mouth and associated structures, photographs, and conference with previous or concurrent treating health professionals, Diagnostic procedures or consultations will be discussed with you. TREATMENTRECOMMENDATIONS:Are based on information gained from initial diagnostic procedures and previous experience and may vary for similar situations. The ultimate goal of treatment is to assist you in attaining optimum dental health and appearance. We will discuss with you the most appropriate and ideal treatment plan as well as reasonable alternative treatment plans. In those instances where supporting structures are compromised, recommendations can be made only after consultation with specialists. We will also inform you of the likely dental prognosis for each of these treatment plans and dental prognosis if no treatment is initiated at this time. You are welcome at any time to seek a second opinion. ANESTHETICS:Most procedures are performed with a local anesthetic (commonly referred to as Novocain and Zylocaine). In addition, sedative and pain medications can be used to help minimize anxiety and discomfort. In rare instances, allergic reactions may cause drowsiness. Therefore, when these medications are used, you would need to make - arrangements for transportations with another person to and from the office. Nitrous Oxide Sedation (laughing gas) may be used if needed as well. DENTALTREATMENTDURINGPREGNANCY: Elective procedures or procedures that can be easily postponed should generally wait until after childbirth. Treatment of dental pain and urgentjarocedures can be performed with relative safety to the fetus by minimizing the use of medications and avoiding the use of nitrous oxide and other medications with known fetal effects. Therefore, it is essential that you inform Family First Dentistry of a confirmed or suspected pregnancy. MEDICAL HISTORY:I understand the medical and dental history is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency. I will notify Family First Dentistry of any change in my health or medication prior to treatment. TREATMENT: Upon such diagnosis, I authorize Family First Dentistry of the designated staff person to perform all recommended treatment employ such assistance as required providing proper care..,- mutually agreed upon by me and to INFORMED CONSENTAND AUTHORIZATION: I certify that I have read and understand this informed consent, which outlines the general treatment considerations as well as the potential problems and complications of dental treatment. iunderstand that potential complications and problems may in;lude, but are not limited to, those described in the document and/or discussed with me I understand that during and following the treatment and in the future, conditions may become apparent that warrant additional or alternative treatment pertinent to the successof comprehensive treatment. Recognizing the potential problems and risks of dental treatment, authorization is given for dental treatment to be rendered by the dentist and office staff. I also approve any modification in design, materials or care, if it is felt this is for my best interest. I also give my permission to have Family First Dentistry Dental Office personally contact me and remind me of needed appointments through the U.S. mail (postcards or letters), , and/or voice messages at home or work. This consent is in force indefinitely unless revoked by me in writing. PAYMENT: I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand the payment is due at the time of service unless other arrangements have been made. I authorized payment directly to Family First Dentistry Dental Office of any insurance benefits otherwise payable to me. I authorize the release of any information relating to dental claims I understand that I am financially responsible for all changes when they are not paid by my insurance. I hereby authorize Family First Dentistry to release all information necessary to secure payment. Please remember that insurance is considered a "method of reimbursing" the patient for fees paid to the doctor and usually does not cover all costs for services therefore, it is not a payment substitute. Some insurances companies pay a fixed allowance for certain procedures while others pay percentage of the change. It is my responsibility to pay any deductible or any balance to this office that is not paid by my insurance. FEE:Lastly, I agree that if I am unable to make my appointment, cancellation fee. I will cancel my appointment 48 hours before the scheduled time or I agree to pay the $75 dollar no show/no PATIENT(ORG.UARDIAN)PRINTEDNAME PATIENT(ORGUARDIAN)SIGNATURE DATE

8 ~~ ~FAMILY FIRST DENTISTRY 1611 SANDS PLACE SE, SUITE 100, Mj\RIETTA, GA PHONE: FAX: National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful enforcement official having la'l,{fulcustody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages,postcards, or letters). it; PATIENTRIGHTS:Access;You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain accessto your health information. You may obtain a form to request accessby using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you $20 cents for each page $15.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request (that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. t Amendment: You have the right fo request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this notice on our web site or by electronic mail ( ), you are entitled to receive this notice in written form. QUESTIONSAND COMPLAINTS:If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about accessto your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.s. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S.Department of Health and Human Services Contact: Family First Dentistry 1611 Sands PlaceSE,Suite 100 Marietta, GA Phone Fax I acknowledge receipt of the notice of privacy practice American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplications or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice and covers only federal, not state law (August 14, 2002).