This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk tor contracting COVID-19.

Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Do you have a fever or above normal temperature? YES NO

Have you experienced shortness of breath or had trouble breathing? YES NO

Do you have a dry cough? YES NO

Do you have a runny nose? YES NO

Have you recently lost or had a reduction in your sense of smell? YES NO

Do you have a sore throat? YES NO

Have you been in contact with someone who has tested positive or COVID-19? YES NO

Have you tested positive for COVID-19? YES NO

Have you been tested for COVID-19 and are awaiting results? YES NO

Have you traveled outside the United States by air or cruise ship in the within the past 14 days?

YES NO

Have you traveled within the United States by air, bus or train within the past 14 days?

YES NO

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

_____________________________________ __________________________Signature Date

COVID-19 Pandemic-Patient Disclosures

PATIENT INFORMATIONName: __________________________________________________________________________________________________________________ Birthdate: ________________________________

Preferred name: ______________________________________________________Soc. Sec.# _____________________________________ Phone ____________________________________ _

Address:_________________________________________________________________________________________City: _______________________________Zip:___________________________

Sex: DMale DFemale DUnspecified Marital Status: DMinor DSingle DMarried/Partner

Last Name First Name Initial

WELCOME NEW PATIENT

Person Responsible for Account _______________________________________________________________________________ Relationship to Patient ________________________

Employer /School____________________________________________________________________________________ Work Phone ____________________________________________ _

Work Address ________________________________________________________________________________________ Occupation ______________________________________________ _

Email______________________________________________________________________________Who should we thank for referring you? ___________________________________

In case of emergency, who should we contact______________________________________________________ Phone __________________________________________________ _

INSURANCE

Subscriber Name _______________________________________________________________Birthdate ____________________________ Soc. Sec.# _____________________________ _

Address ___________________________________________________________________________________Relationship to patient_____________________________________________

Insurance Company _______________________________________ _ Group #__________________________________Subscriber/Member ID_________________________________

Insurance Company Address _________________________________________________________________________________Phone___________________________________________

ASSIGNMENT AND RELEASE I, the undersigned, certify that I (or my dependent) have insurance coverage as indicated above and assign directly to We Care Dental Florida

all insurance benefits, if any, otherwise payable to me for services rendered.

II understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all

information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Signature______________________________________________________________________________________________________________

Print Name____________________________________________________________________________________________________________

Date_________________________________

DENTAL HISTORYFormer Dentist _______________________________________________City, State _________________________________ _ Date of Last Dental Visit ______________________________ _

How often do you brush?___________________________________________________________________floss?___________________________________________________________________

How happy are you with your smile?_______________________________________________________________________________________________________________________________

Reason for visit_______________________________________________________________________________________________________________________________________________________

Please check all that apply:

Bad Breath .........................................

Bleeding gums..................................

Broken/Loose teeth......................

Mouth Sores......................................

If yes, age of dentures____________________

D Tooth Pain.......................................... D Issues Chewing/Swallowing....... D

D Sensitivity to Hot/Cold.................. D Pain in Jaw/TMJ................................ D

D Sensitivity to Biting......................... D Teeth Grinding/Clenching............ D

D Frequent Headaches....................... D Clicking/Popping Jaw...................... D

Yes No

Do you require prem edication before dental procedures?................................................. D D

Have you ever been treated for periodontal/gum disease?................................................ D D

Have you ever had a reaction from local anesthetics such as Novocaine?..................... D D

Are you currently wearing dentures?............................................................................................. D D

ALLERGIES

Have you had any allergic reactions to any of the following:

Metal............ Sulfa Drugs. Acrylic........... Penicillin.................

Latex............. Codeine........ Aspirin.......... Other Antibiotics.

Other, please explain__________________________________________________________________________________________________________

PHARMACY ((optional)

Pharmacy___________________________________________________Phone_________________________________________Cross-Streets___________________________________________

To the extent permitted by applicable law, authorize this dental practice (or their designees) to collect information about my prescription history from my pharmacy and insurers as applicable)and give my pharmacy and insurers permission to disclose such information.

Signature______________________________________________________________________________________________________________

Print Name____________________________________________________________________________________________________________

Date_________________________________

Yes No Yes No Yes No Yes No

D D D D D D D DD D D D D D D D

MEDICAL HISTORYPhysician__________________________________________________________Phone___________________________________ _ Date of Last Visit ____________________________

If yes, please explain__________________________________________________________________________

If yes, please list_______________________________________________________________________________

If yes, please explain__________________________________________________________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that

providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental

office of any changes in medical status.

Signature______________________________________________________________________________________________________________

Print Name____________________________________________________________________________________________________________

Date_________________________________

Yes NoAre you currently under medical treatment ?................................ D D

Are you taking any medications?......................................................... D D

Have you ever been hospitalized?...................................................... D D

Do you take, or have you taken PhenFen or Redux?.................. D D

Yes No Cortisone Medicine Yes No Hepatitis A Yes No Radiation Treatments Yes No Yes No Diabetes Yes No Hemophilia Yes No Recent Weight Loss Yes No Yes No Drug Addiction Yes No Hepatitis B or C Yes No Renal Dialysis Yes No Yes No Easily Winded Yes No Herpes Yes No Rheumatic Fever Yes No Yes No Emphysema Yes No High Blood Pressure Yes No Rheumatism Yes No Yes No Epilepsy or Seizures Yes No High Cholesterol Yes No Scarlet Fever Yes No Yes No Excessive Bleeding Yes No Hives or Rash Yes No Shingles Yes No Yes No Excessive Thirst Yes No Hypoglycemia Yes No Sickle Cell Disease Yes No Yes No Fainting /Dizziness Yes No Irregular Heartbeat Yes No Sinus Trouble Yes No Yes No Frequent Cough Yes No Kidney Problems Yes No Spina Bifida Yes No Yes No Frequent Diarrhea Yes No Leukemia Yes No Stom/Intestinal Disease Yes No Yes No Frequent Headaches Yes No Liver Disease Yes No Stroke Yes No Yes No Genital Herpes Yes No Low Blood Pressure Yes No Swelling of Limbs Yes No Yes No Glaucoma Yes No Lung Disease Yes No Thyroid Disease Yes No Yes No Hay Fever Yes No Mitral Valve Prolap Yes No Tonsillitis Yes No

AIDS/HIV Positive Alzheimer's Anaphylaxis Anemia Angina Arthritis/Gout Artificial Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores ConvulsionsCongenital Heart Disorder

Yes No Heart Attack/Failure Yes No Yes No Tuberculosis Yes No Heart Murmur Yes No

Osteoporosis Pain in Jaw Yes No Tumors or Growths Yes No

Heart Pacemaker Yes No No Ulcers Yes No Venereal Disease Yes No Yes No Heart Trouble/Disease Yes No Psychiatric Care Yes No

Have you ever taken osteoporosis medications such as Boniva or any medications containing bisphosphates.......... D D

Do you smoke?............................................................................................. D D

Do you use controlled substances?..................................................... D D

Do you have , or have you had, any of the following:

Yes No Yes No Parathyroid Issues Yes

Women are you:

Pregnant/trying to get pregnant? ........

Taking oral contraceptives? ...................

Nursing? ..........................................................

Yes No D D

D D

D D

m

Cancellation Policy

All appointments canceled less than 24 hours in advance may be subject to a penalty payment of $25 per hour of

appointment or as per your insurance regulations for codes D9986 or D9987. If you have any questions regarding

this policy, please ask us.

Signature______________________________________________________________________________________________________________

Print____________________________________________________________________________________________________________

Date_________________________________

Notice of Privacy Practices

By signing below, I acknowledge that I have provided the Notice of Privacy Practices (separate handout at the end of the New

Patient forms), as mandated by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

Signature______________________________________________________________________________________________________________

Print____________________________________________________________________________________________________________

Date_________________________________

Financial policies

We Care Dental Florida is committed to providing exceptional service and treatment. We try to make it easier for you to get the care you need with no hidden fees or surprises. Please read the our payment policy and sign below.

You will be given a comprehensive treatment plan based on your overall health. You’ll also receive a clear, detailed estimate of the cost of your plan, including your estimated insurance benefits. If you have questions regarding your insurance coverage, please contact your insurance company.

Full payment of what you owe is due when services are rendered.

We accept cash, personal checks, Visa®, Master Card®, American Express®, Discover®, assigned insurance benefits, and select third-party financing programs.

By signing below, I acknowledge that I have read the Financial Policies and agree to abide by such policies.

Signature____________________________________________________________________________________________________________

Print_________________________________________________________________________________________________________________

Date_________________________________

Communication policies

We’d like to keep in touch regarding your upcoming appointments, treatment plan, and treatment status. By providing your email address, phone number, and mailing address, you are giving We Care Dental Florida permission to contact you through one or all of these communication methods.

Note that email and text messaging is not secure and there is a risk that they could be read by a third party. By sharing your email or mobile number with us you are acknowledging that you are aware of this risk and agree to receive this type of communication.

Please rank your preferred communication method:

_____ Email

_____ Mobile phone

_____ Text message

_____ Other, please specify:__________________________________________________________________

Authorization for Release of Health Records to External Parties (optional)

This section is regarding sharing my/the patient's treatment information with family or other designated parties.

I authorize the disclosure of information from my treatment records to_______________________________________________________________

_______________________________________________________________________________________________________________.

Signature____________________________________________________________________________________________________________

Date_________________________________________________________________________________________________________________

Date_________________________________

I give authorization to disclose the following information:

all treatment information.

information specifically related to these treatment dates ____________________________________________________