WELCOME TO MICHAEL EDLIN, DMD

PATIENT Last Name Street Address Cell Ph ne Se! Em'l yer "irthday H me Ph ne S #ial Se#$rity % W r( Ph ne First Name City Email Marital Stat$s O##$'ati n & Middle Initial Preferred Name State ZIP

Email Address&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& Preferred Meth d f r A'' intment C nfirmati ns) Emer,en#y C nta#t RESPONSIBLE PARTY *If patient is a Minor+ Street Address Cell Ph ne Se! Em'l yer "irthday H me Ph ne S #ial Se#$rity % W r( Ph ne Ph ne Te!t Email * please circle one+ Ph ne

Last Name

First Name City Email

Middle Initial State ZIP

Marital Stat$s O##$'ati n

&

Email Address&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& Preferred Meth d f r A'' intment C nfirmati ns) REFERRAL SOURCE Please let $s (n - -h t than( f r referrin, y $ t $s r h - y $ heard a. $t $r 'ra#ti#e: PRIMARY DENTAL INSURANCE INFORMATION Name f Ins$red Last Name "irthday Ins$ran#e Carrier S #ial Se#$rity % Ph ne % First Name Em'l yer /r $' % Middle Initial Ph ne Te!t Email * please circle one+

SECONDARY DENTAL INSURANCE INFORMATION (If Applicable) Name f Ins$red Last Name "irthday Ins$ran#e Carrier S #ial Se#$rity % Ph ne % First Name Em'l yer /r $' % Middle Initial

MINOR/CHILD CONSENT I, .ein, the 'arent r ,$ardian f *Name f Min r0Child+ d here.y re1$est and a$th ri2e the dental staff t 'erf rm ne#essary ser3i#es f r my #hild, in#l$din, .$t n t limited t 45 rays, and an administrati n f anestheti#s -hi#h are deemed ad3isa.le .y the d #t r, -hether r n t I am 'resent at the a#t$al a'' intment -hen the treatment is rendered6 Patient, Parent or Guardian Signature Date: (Must be 18 years or older to sign)

DENTAL HISTO78 AND CONCE7NS

What is y $r #hief # m'laint9 D es fl ss shred -hen y $ $se it9 8es N D es f d 'a#( r #at#h .et-een y $r teeth9 8es N D es y $r .reath # n#ern y $9 8es N

D y $ sm (e r #he- t .a## 9 8es N

D y $r ,$ms .leed9 8es N 8es N 8es N

Ha3e y $ .een instr$#ted re,ardin, 'r 'er h me #are9 Ha3e y $ had .ra#es r ther rth d nti# treatment9 Ha3e y $ had any # smeti# 'r #ed$res9 8es N

Name f Orth d ntist

If s , 'lease list

When -as y $r last dental a'' intment and #leanin,9 Please indi#ate if y $ ha3e any f the f ll -in, # n#erns *#he#( all that a''ly+) My teeth are n t in ali,nment Chi''ed Teeth Old Fillin,s, ;eneers, r Cr -ns O3erall a''earan#e f my smile Has the fear f dis# mf rt (e't y $ fr m re,$lar dental 3isits9 What is the reas n f r tryin, a ne- dental ffi#e9 8es N I ha3e s'a#es I d n:t li(e Pr tr$din, teeth TM< Dis rder I d n t li(e the # l r f my teeth Hidden r missin, teeth I am $nha''y -ith my fa#ial 'r file

Are there any additi nal # n#erns y $ - $ld li(e $s t (n -

MEDICAL HISTO78
Medi#al health 'r .lems that y $ may ha3e, r medi#ati ns that y $ may .e ta(in,, # $ld .e im' rtant t health6 Than( y $ f r thoroughly ans-erin, the f ll -in, 1$esti ns6 Family Physi#ian && Are y $ ta(in, any medi#ati n n -, in#l$din, re,$lar d sa,es f as'irin9 8es Ph ne % N y $r dental

&&&&&&&&&&&&&&&&&&&&&&&&&&

D sa,e &&&&&&&&&&&&&&&&&&&&&&&&& Aller,y&&&&&&&&&&&&&&&&&&&&&&&&&

Are y $ a-are f ha3in, an aller,i# rea#ti n t any medi#ati n r s$.stan#e9 8es N Ha3e y $ .een $nder the #are f a medi#al d #t r d$rin, the 'ast t- years9 8es N If s , f r -hat9 Ha3e y $ e3er had heart s$r,ery, heart 3al3e r = int re'la#ement, r r,an trans'lant9 If s , f r -hat and -hen9 D y $ re1$ire 'remedi#ati n9 8es N If s , f r -hat9 &

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 8es N &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&& N

D y $ r ha3e y $ ever ta(en F sama! r any ther .is'h s'h nate, Z meta, Aredia, " ni3a, r A#t nel9 8es W men) Are y $ Pre,nant9 N$rsin,9 Ta(in, "irth C ntr l Pills9 8es N 8es N Name Name

Ha3e y $ seen an ENT *ear, n se, and thr at d #t r+9 Ha3e y $ seen a ne$r l ,ist9

Indi#ate -hi#h f the f ll -in, y $ have ever had, or have at present. Cir#le >yes? r >n ? t ea#h item6 Heart C n#erns C n,enital Heart Disease Heart M$rm$r Hi,h "l d Press$re Mitral ;al3e Pr la'se Artifi#ial Heart ;al3e Pa#ema(er Late! Aller,y Artifi#ial < ints @idney Tr $.le 7adiati n0Chem thera'y E'ile'sy0Sei2$res He'atitis Psy#hiatri# Dis rders Dia.etes Thyr id Dis rder N tes0Any ther health iss$es Medi#al A'dates &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& I $nderstand the a. 3e inf rmati n is ne#essary t 'r 3ide me -ith dental #are in a safe and effi#ient manner6 I ha3e ans-ered all 1$esti ns t the .est f my (n -led,e6 Sh $ld f$rther inf rmati n .e needed, y $ ha3e my 'ermissi n t as( the res'e#ti3e health #are 'r 3ider -h may release s$#h inf rmati n t y $6 I -ill n tify Dr6 Edlin f any #han,e in any health r medi#ati n6 Patient, Parent or Guardian Signature Date: (Must be 18 years or older to sign) 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es N N N N N N N N N N N N N N N N Ne$r l ,i#al Dis rders Oste ' r sis Li3er Disease0=a$ndi#e Si#(le Cell Disease Asthma AIDS0HI; Str (e An,ina Anemia Al#ers T$.er#$l sis Arthritis Diffi#$lty Che-in, Ins mnia0Ner3 $sness Teeth Clen#hin,0/rindin, Sn rin,0Slee' A'nea 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es N N N N N N N N N N N N N N N N Heada#hes Ne#( A#he 7in,in,0C n,ested Ears Fa#ial Pain Sensiti3e Teeth *H t0# ld+ Diffi#$lty S-all -in, Tin,lin, in arms0fin,ers <a- Cli#(in,0P ''in, Di22iness P st$re Pr .lems Tri,eminal Ne$ral,ia "ell:s Palsy <a- Pain Limited M $th O'enin, L se Teeth 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es 8es N N N N N N N N N N N N N N N

FINANCIAL 7ESPONSI"ILITIES B PA8MENT OPTIONS

O$r missi n is t deli3er the .est and m st # m'rehensi3e dental #are6 Finan#ial # nsiderati ns sh $ld n t .e an .sta#le in f$lfillin, y $r needs, theref re -e 'r 3ide a ran,e f 'ayment 'ti ns f r $r 'atients6 FOR YOUR CON !N"!NC! #! $CC!P% C&!C', C$S&, D!("% C$RD, D"SCO !R C$RD "N OUR OFF"C!, $S #!** $S "$ %!*!P&ON!. "NSUR$NC! P*$NS We a##e't all dental 'lans e!#l$din, Medi#aid and -ill - r( t ma!imi2e y $r dental .enefits6 We are als ha''y t s$.mit y $r ins$ran#e #laims at n #har,e6 F r y $r # n3enien#e, -e -ill a##e't the ins$ran#e .enefit dire#tly fr m y $r ins$ran#e # m'any, and nly the estimated # 'ay 'er#enta,e n t # 3ered .y y $r ins$ran#e is d$e at the time treatment is 'erf rmed6 As there is n -ay t ,$arantee the e!a#t am $nt f y $r ins$ran#e reim.$rsement, d$e t 3ari $s >7eas na.le and C$st mary Fees? $sed .y e3ery ins$ran#e # m'any, any ins$ran#e reim.$rsement that is less than the am $nt -e >estimated?, -ill res$lt in an a## $nt .alan#e in -hi#h y $ -ill .e res' nsi.le6 *E!#e'ti n) Delta Dental mem.ers -ill .e reim.$rsed dire#tly fr m Delta Dental, theref re all 'ayments are d$e in f$ll at the time f ser3i#e6 We -ill ha''ily s$.mit y $r #laim and y $ -ill .e reim.$rsed dire#tly fr m Delta Dental6+ Assignment and Release: 8 $, the $ndersi,ned, assi,n dire#tly t Mi#hael Edlin, DMD all .enefits, if any, ther-ise 'aya.le t y $ f r ser3i#es rendered6 8 $ here.y a$th ri2e the d #t r t release all inf rmati n ne#essary t se#$re the 'ayment f .enefits6 8 $ a$th ri2e the $se f y $r si,nat$re n all y $r ins$ran#e s$.missi ns -hether man$al r ele#tr ni#6 "S$, )$S%!RC$RD $ND

F*!+"(*! SP!ND"NG $CCOUN%S If y $ - r( f r a # m'any that 'r 3ides a fle!i.le s'endin, a## $nt, r a >fle!5'lan,? -e -ill 'r 3ide y $ -ith all the d #$mentati n ne#essary t re#ei3e reim.$rsement fr m s$#h 'lans6 P*!$S! NO%! S me 'r #ed$res s$#h as dent$res, #r -ns, .rid,es and ther ma= r rest rati3e - r( -ill re1$ire half 'ayment at the first a'' intment, referred t as the >'re' date?, -hi#h is the date -e send t $r s'e#ialty la.s f r fa.ri#ati n6 The .alan#e -ill .e d$e at the se# nd r final a'' intment, referred t as the >seat r deli3er date?, -hi#h is the date y $r nerest rati n is #emented6 A## $nt .alan#es C A finan#e fee f D6EF 'er m nth -ill .e a''lied t $n'aid .alan#es6 There -ill .e a GHI #har,e f r all ret$rned #he#(s6 Any a## $nt .alan#e that , es 'ast DJI days -ill .e sent t an $tside # lle#ti n a,en#y6 All # lle#ti n fees -ill .e added t the 'ast d$e .alan#e6 I ha3e read the Finan#ial P li#y in its entirety and $nderstand and a,ree t all its terms6 Patient, Parent or Guardian Signature (Must be 18 years or older to sign) Date:

NOTICE OF P7I;AC8 P7ACTICES

R!*!$S! OF "NFOR)$%"ON I a#(n -led,e that there are instan#es -hen Dr6 Edlin, DMD m$st release inf rmati n # n#ernin, my #are, in#l$din, # 'ies f my medi#al0dental re# rds, t #ertain indi3id$als -h are in3 l3ed in my #are, 'ayment f r my #are, and ther a#ti3ities related t my #are6 S$#h dis#l s$res are m re f$lly des#ri.ed in NOTICE OF P7I;AC8 P7ACTICESK and in#l$de dis#l s$res t ) a6 .6 Any health 'r fessi nals in3 l3ed in my #are f r the '$r' se f fa#ilitatin, the # ntin$ity f my dental #are6 Any 'ers n r entity res' nsi.le f r, r any 'ers n r entity a#tin, as a,ent f r the 'arty res' nsi.le f r 'ayment, rd in#l$din, H 'arty 'ayers, self5ins$rers, - r(er:s # m'ensati n #arriers and , 3ernmental a,en#ies, 'ayment f r the dental ser3i#es rendered t me at this 'ra#ti#e .y their em'l yees r any 'ers n 'r 3idin, ser3i#es at this 'ra#ti#e6 Any federal, state r ther , 3ernmental r 1$asi5, 3ernmental a,en#ies '$r' ses f re' rtin,6 f ther s$#h 'arties as re1$ired .y la- f r

#6 d6

Any # ntin$in, #are, residential r l n,5term #are fa#ility, r h me health a,en#y f r the '$r' se f 'r 3idin, ser3i#es f r my #are6

I a#(n -led,e that my medi#al0dental inf rmati n may in#l$de inf rmati n relati3e t al# h l a.$se, dr$, a.$se, 'sy#h l ,i#al r 'sy#hiatri# # nditi ns, H$man Imm$n defi#ien#y ;ir$s *HI;+ and0 r A#1$ired Imm$n defi#ien#y Syndr me *AIDS+6 I here.y ,i3e my 'ermissi n f r the $se f 'h t ,ra'hs and !5rays made in the 'r #ess f e!aminati n, treatment, and retenti n f r '$r' ses f # ns$ltati ns, resear#h, ed$#ati n, r '$.li#ati n6 If I -as referred .y a medi#al 'ra#titi ner, I here.y ,i3e my 'ermissi n that any and all rele3ant medi#al data in#l$din, .$t n t limited t #ase n tes .e re' rted t the 'ra#titi ner6 I a#(n -led,e that I ha3e read this f rm and $nderstand its # ntents f$lly and ha3e re#ei3ed a # 'y f the NOTICE OF P7I;AC8 P7ACTICES6 I a,ree t f ll - the r$les and re,$lati ns f this 'ra#ti#e, and $nderstand that these r$les and re,$lati ns a''ly n t nly t 'atients f this 'ra#ti#e, .$t t the 'atient:s 3isit rs as -ell6

Patient, Parent or Guardian Signature (Must be 18 years or older to sign)

Date:

LATE0CANCELLATION POLIC8

The D #t r and Team f Mi#hael Edlin, DMD - $ld li(e t as( f r y $r # 'erati n in hel'in, $s .etter ser3e y $6 The s#hed$lin, f y $r a'' intment deser3es a reser3ed time that needs t .e f ll -ed .y $r team and $r 'atients6 "ein, n time is essential f r y $r a'' intment6 If y $r arri3al is m re than DE min$tes late, -e -ill e3al$ate -hat #an .e a## m'lished in the all -ed time left f the a'' intment6 M re than t- missed a'' intments -ith $t a LM5h $r n ti#e -ill res$lt in a fee f GEI6 Than( y $ f r y $r # mmitment s that -e #an 'r 3ide the .est #are t all $r 'atients6 Patient, Parent or Guardian Signature (Must be 18 years or older to sign) Date: