Spouse's Work ( ) Best time and place to reach you _ IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.

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PATIENT Date INF\ORMATION W E L ( 0 M DENTAL I NSVRAN(E E Who is responsible for this account? SS/HIC/Patient 10 # Patient ~ Relationship to Patient -----=,,------------- Insurance Co. -------- Address Group # City State E-mail --- Zip Sex 0 M 0 F Age ~~ Birthdate o Married o Separated Occupation Patient Employer/School DWid~wed o Divorced o Single o Minor o Partnered for years Employer/School Address Employer/School Phone ( ) Spouse's Name Is patient covered by additional insurance? 0 Yes 0 No Subscriber's Name Birthdate SS# Relationship to Patient Insurance Co. -- Group # ~ ~ ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with -----.;=~70::::C:=-=-=-=====--- and assign directly to Name of Insurance Company(ies) Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Birthdate SS# ------------------------- Spouse's Employer Whom may we thank for referring you? PHONE NVMBERS Signature of Patient, Parent, Guardian or Personal Representative Please print name of Patient, Parent, Guardian or Personal Representative.. Date Relationship to.patient Home ( ) Work ( ) Ext Cell Phone ( ) Spouse's Work ( ) Best time and place to reach you IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.) Name ------------ Relationship Home Phone ( ) Work Phone ( ) ------------- DENTAL HISTORY Reason for today's visit ~ Former Dentist City/State Date of last dental visit Date of last dental X-rays Place a mark on ''yes'' or "no" to indicate if you have had any of the following: Sad breath Bleeding gums. Blisters on lips or mouth Burning sensation on tongue DYes DNo Mouth breathing DYes DNo Chew on one side of mouth DYes DNo Mouth pain, brushing DYes DNo Cigarette, pipe, or cigar smoking DYes DNo Orthodontic treatment DYes DNo Clicking or popping jaw DYes DNo Pain around ear DYes DNo Dry mouth DYes DNo Periodontal treatment DYes ONo Fingernail biting DYes DNo Sensitivity to cold DYes ONo Food collection between the teeth DYes ONo Sensitivity to heat DYes DNo Foreign objects DYes DNo Sensitivity to sweets DYes DNo Grinding teeth DYes DNo Sensitivity when biting DYes DNo Gums swollen or tender DYes DNo Sores or growths in your mouth DYes DNo Jaw pain or tiredness DYes DNo Lip or cheek biting DYes DNo Loose teeth or broken fillings DYes DNo How often do you floss?

HEALTH HISTORY ------ Physician's Name Date of last visit Have you ever taken any of the group of drugs collectively referred to as "fen-phon?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). 0 Yes ONo Place a mark on "yes" or "no" to indicate if you have had any of the following: AIDS/HIV DYes ONo Epilepsy DYes ONo Respiratory Disease DYes ON ) Anemia DYes ONo Fainting er dizziness LlYes ONo Rheumatic Fever DYes ono Arthritis, Rheumatism DYes ONo Glaucoma DYes ONo Scarlet Fever DYes ONo Artificial Heart Valves DYes ONo Headaches DYes ONo Shortness of Breath DYes DNo Artificial Joints DYes ONo Heart Murmur DYes ONo Sinus Trouble DYes LJ No Asthma DYes ONo Heart Problems DYes ONo Skin Rash DYes LI No Back f'roblems DYes ONo Hepatitis Type DYes ONo Special Diet DYes ONo Bleeding abnormally, witl1 DYes ONo Herpes DYes ono Stroke DYes ONo extractions or surgery High Blood Pressure DYes ONo Swollen Feet Of Ankles DYes ONo Blood Disease DYes ONo Jaundice DYes ONo Swollen Neck Glands DYes ONo Cancer DYes ONo Jaw Pain DYes ON0 Thyroid Problems DYes DNa Chemical Dependency DYes ONo Kidney Disease DYes ONo Tonsillitis LJYes ONo Chemotherapy LJYes DNo Liver Disease DYes ONo Tuberculosis DYes DNo Circulatory Problems DYes ONo Low Blood Pressure DYes ONo Tumor or growth on head or DYes ONo Congenital Heart Lesions DYes ONo Mitral Valve Prolapse DYes ONo neck Cortisone Treatments DYes [] No Nervous Problems DYes ONo Ulcer DYes ONo Cough, persistent or bloody DYes ONo Pacemaker DYes ONo Venereal Disease DYes ONo Diabetes DYes ONo Psychiatric Care DYes ONo Weight Loss, unexplained DYes [J No Emphysema DYes ONo Radiation Treatment DYes ONo Do you wear contact lenses? 0 Yes D No Women: Are you pregnant? 0 Yes 0 No Taking birth control pills? 0 Yes 0 No Due date Are you nursing? 0 Yes 0 No MEDI(ATIONS ALLERGIES List any medications you are currently taking and the correlating o Aspirin diagnosis:. - o Barbiturates (Sleeping pills) o Codeine Pharmacy Name ~------''------~----- o Iodine Phone ( ) -------~-------- o Latex o Local Anesthetic o Penicillin D Sulfa o Other v P DATE S (To be filled in at future appointments) Has there been any change in your health since your last dental appointment? 0 Yes 0 No For what conditions? ~-~--~------------------ ~--~ Are you taking any new medications? ~~~ If so, what?,,--'"-=~ "-+- ~~ Patient's Signature~~ ~-=-",~ ~~--~-----=-,~-- Date ~---- Doctor's Signature,~ ~ ~~~~~~~~~ ~ Date~ ~~ Has there been any change in your health since your last dental appointment? 0 Yes 0 No For what conditions? ~~~ ~ ~,=-=-,,=-=,,---, ~~~~ Are you taking any new medications? -- If so, what? ~~ ----- Patient's Signature -------~---------- ------ Date ~ Doctor's Sigl1ature--~------,"--~------------------ Elate ~-----

--- Dr.Mark Kogan D.M.D 1501 Broadway Suite 2012 New York, NY 10036 (212) 302-4132 Patient's Name: --------------------------------------- My personal health information is private and confidential I understand that my Doctor and his staff work very hard to protect my privacy and preserve the confidentiality of my personal health information. I understand that my Doctor and his staff may use and disclose my personal health information to help provide health care to me, to handle billing and payment, and to take care of other health care operations. There will be no other uses and disclosures of this information unless I permit it. However, I understand that sometimes the law may require the release of this information without my permission. I can ask my Doctor to limit how my personal health information is used or disclosed to carry out treatment, payment, or health care operations. I understand that my Doctor does not have to agree to my request. If my Doctor does agree to my request, I understand that my Doctor and his staff would follow the agreed limits. I may cancel this consent at any time by doing one ofthe following: 1. Signing and dating aform that my Doctor or staff can give me called "Revocation of Consent for Use and Disclosure of Health Information". 2. Writing, signing and dating a letter of my doctor directly. If I write a letter, it Must say that I want to cancel my consent to authorize the use and disclosure Of my personal health information for treatment, payment, and health care Operations. If I cancel this consent, mv doctor and staff do not have to provide and further health care service to me. My doctor has a detailed document called the" Notice of Practices". It contains more Information about the policies and practices protecting my privacy. I understand that I have the right to read the "Notice" before signing this agreement. My doctor may update the "Notice. "F I ask, my doctor or his staff will provide me with the most Current "Notice" and the current "Notice" will always be posted at my doctor's office. My signature below indicates that I have been given the chance to review a current copy of my doctor's "Notice of Privacy Practice". My signature means that I agree to Allow my doctor to use and disclose my personal health information to carry out treatment, payment and healthcare operations. Patient or legal authorized signature Date Relationship to patient (legal parent or guardian) -,

Dr. Mark Kogan D.M.D 1501 Broadway Suite 2012 New York, New York 10036 TO OUR VALUED PATIENTS DR. KOGAN'S TIME IS VERY VALUABLE, PLEASE RESPECT HIS TIME AS HE RESPECTS YOUR'S. ANY APPOINTMENT, WHICH IS NOT, CANCELED A T LEAST 24 BUSINESS HOURS (TUES- FRI 8:30AM TO 5:30PM) PRIOR TO THE TIME SET, AND IS NOT KEPT, WILL BE SUBJECT TO A $50 FEE DIRECTLY CHARGED TO THEPATIENT. (INSURANCE PLANS DO NOT PA Y FOR BROKEN APPOINTMENTS) IF YOU ARE RUNNING LA TE PLEASE CALL TO LET US KNOW. THANK YOU FOR YOUR UNDERSTANDING. Signa ture: Date:....

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