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T}^m1Cy©ii f©r sejecfing us.To help us meet all your healthcare needs, please fill out this form completely in ink.

Ifyou have any questions or need assistance, please ask us and we will be happy to help.

&]c©106^Patient Information (Confidential)

Name

SS#/SIN.

Address.

Email

Check Appropriate Box: D Minor D Single

If Student, Name of School/College

Patient or Parent/Guardian's Employer.

Business Address

Spouse or Parent/Guardian's Name

Whom May We Thank for Referring You?

Person to Contact in Case of Emergency

Responsible PartyName of Person Responsible for this Account.

Address

Email

Driver's License i

Employer

Birthdate.

City

CH Married D Separated

City

City_

Employer.

Birthdate

Work Phone.

PatientNumber _

Date

Home Phone .

State/Prov.

Cell Phone.

CD Divorced CD WidowedState/ I—, p-,Prov. I I FullTime I IPart Time

Work Phone.State/Prov.

Work Phone

Phone.

Relationshipto Patient

Home Phone

Cell Phone

Financial Institution.

SS#/SIN_

Is this Person Currently a Patient in our Office? CD Yes CD No

Foryour convenience, we offer the following methods of payment Please check the option you prefer. Payment in full at each appointment.

CD Cash CD Personal Check Credit Card CD VISA CD MasterCard CD Iwish to discuss the office's payment policy.

Insurance Information

Name of Insured

Birthdate SS#/SIN Date Employed.

Name of Employer.

Employer Address.

Insurance Company

Ins. Co. Address

How Much is Your Deductible?.

Union or Local)

City

Group)

City

How Much Have You Used?

Do You Have Any Additlonallnsurance? ElYes CD No If Yes, Complete the Foilowing

Name of Insured.

Birthdate

Name of Employer.

Employer Address.

Insurance Company

Ins. Co. Address

SS#/SIN.

How Much is Your Deductible?.

Union or Local I

City

Group)

City

How Much Have You Used? ,

Over Please

Relationshipto Patient

Work Phone.State/Prov.

Policy/ID#.State/Prov. wMax. Annual Benefit

Relationshipto Patient

Date Employed.

Work PhoneState/ ZiProv. P.

Policy/ID#State/ Zip/Prov. PC..

Max. Annual Benefit

Patient Medical HistoryPhysician Office Phone

Yes No

• •

Date of Last Exam

1, Are you under medical treatment now?

2. Have you ever been hospitalized for any surgicaloperation or serious illness within the last 5 years?Ifyes, please explain

3. Are you taking any medication(s) including non-prescription medicine?Ifyes, what medication(s) are you taking?

4. Have you overtaken Fen-Phen/Redux?

5. Have you overtaken Fosamax, Boniva, Actonel or anycancer medications containing bisphosphonates?

6. Have you taken Viagra, Revatio, Cialis or Levitra inthe last 24 hours?

7. Do you use tobacco?

8. Doyou USB controlled substances?

9. Doyou have or have you had any of the following?

• •

• •

• •

• •

• •

• •

• •

10. Are you wearing contact lenses?

11. Are you allergic to or have you had any reactions to the following?Local Anesthetics (e.g. Novocain)Penicillin or any other AntibioticsSulfa DrugsBarbiturates

Sedatives

Iodine

Aspirin

Any Metals (e.g. nickel, mercury, etc.)Latex Rubber

Dther

12. Doyou have a persistent cough or throat clearing not

Yes No

• •

••••••••••

••••••••••

Yes No

High Blood Pressure • • Heart Disease

Heart Attack • • Cardiac Pacemaker

Rheumatic Fever • • Heart Murmur

Swollen Ankles • • Angina

Fainting/Seizures • • Frequently Tired

Asthma • • Anemia

Low Blood Pressure • • Emphysema

Epilepsy/Convulsions • • Cancer

Leukemia • • Arthritis

Diabetes • • Joint Replacement or Implant

Kidney Diseases • • Hepatitis/Jaundice

AIDS or HIV Infection • • Sexually Transmitted Disease

Thyroid Problem • • Stomach Troubles/Ulcers

Patient Dental HistoryName of Previous Dentist and Location

associated with a known Illness (lasting more than 3 weeks)? • •

Women Only:Are you pregnant or think you may be pregnant? • •Are you nursing? • •Are you taking oral contraceptives? • •

Yes No Yes No

• • Chest Pains • •

• • EasilyWinded • •

• • Stroke • •

• • Hay Fever/Allergies • •

• • Tuberculosis • •• • Radiation Therapy • •

• • Glaucoma • •

• • Recent Weight Loss • •

• • Liver Disease • •

• • Heart Trouble • •

• • Respiratory Problems • •

• • Mitral Valve Prolapse • •

• • Other • •

Date of Last Exam

Yes No Yes No

1. Do your gums bleed while brushing or flossing? • • 8. Do you have frequent headaches? • •

2. Are your teeth sensitive to hot or cold liquids/foods? • • 9. Do you clench or grind your teeth? • •

3. Are your teeth sensitive to sweet or sour liquids/foods? • • 10. Do you bite your lips or cheeks frequently? • •

4. Doyou feel pain to any of your teeth? • • 11. Have you ever had any difficultextractions in the past? • •

5. Doyou have any sores or lumps in or near your mouth? • • 12. Have you ever had any prolonged bleeding

6. Have you had any head, neck or jaw injuries? • • following extractions? • •

7. Have you ever experienced any of the following 13. Have you had any orthodontic treatment? • •

problems in your jaw? 14. Do you wear dentures or partials? • •

Clicking • • If ves. date of alacement

Pain (joint,ear, side of face) • • 15. Have you ever received oral hygiene Instructions

Difficulty in opening or closing • • regarding the care of your teeth and gums? • •

Difficultyin chewing • • 16. Do you like your smile? • •

Authorization and Release

1certify that 1have read and understand the above informationto the best of my knowledge. to the dentist or dental groupinsurance benefitsotherwise payableto me.11understand

The above questions have been accurately answered. I understand that providing incorrectinformation can be dangerous to myhealth. I authorizethe dentist to release any informationincluding the diagnosis and the records of any treatment or examination rendered tome or mychildduringthe periodof such Dentalcare to third party payors and/or healthpractitioners. I authorizeand request myinsurance companyto pay directly

that mydental insurance carrier may pay less than the actual bill for services. I agree to beresponsible for payment of all services rendered on my behalfor mydependents.

XSignature of patient (or parent/guardian ifminor)

Doctor's Comments

Signature _r-s_ Date

M998 PATTERSON OFFICE SUPPLIES 1.800.637.1140 0561993/17694

Acknowledgement of Receipt ofNotice of Privacy Practices

For

R. Nicholas Cost, D.D.S., PA318 W. Farley Ave.Laurens, SO 29360

I hereby acknowledge that I have received the Notice of Privacy Practices for theabove office.

Signature: Patient's Name / Personal Representative (as defined by HIPAA) Date

Description of Personal Representation and please attach copy of documentation.

Documentation of "Good Faith" Attempt to get acknowledgementsignature.

• Document presented to patient, but patient refused to signacknowledgement.

• Patient presented with an emergency situation and there was no time togive the Notice or receive a signature. Attempt to get give the Notice, andget any acknowledgement will be handled as soon as possible.

• Documentation was presented to the patient but a communication failureprevented us from receiving the acknowledgement.

• The documentation was mailed to the patient but never returned to us.

• Other

Employee preparing document Date

Employee signature

Authorization Form- General

This authorization form permits:R. Nicholas Cost, D.D.S., P.A.

318 West Farley AvenueLaurens, SO 29360

to use or disclose protected health information listed in the description section below forthe following patient:

Name Birth DateAddressCity/State/ Zip

Entity or person to receive the information:NameAddressCity/State/ Zip.

Description of information to be used or disclosed:

Purpose of use or disclosure:

Expiration date or event:

Rights of the Patient

I understand that I have the right to refuse to sign this authorization and that mytreatment will not be conditioned on signing,

I understand that I have the right to revoke this authorization at any time by sending awritten notification to the address listed at the top of this form I understand that arevocation is not effective in cases where the information has already been used ordisclosed but will be effective going fonward,

1understand that information used or disclosed as a result of this authorization may besubject to redisclosure by the recipient and may no longer be protected by federal orstate law.

DateSignature of Patient or Personal Representative (as defined by HIPAA)

Description of Personal Representative's Authority (attach necessary documentation)

********************************************************************************************

Office Use Only:

Receiving Employee_, Date received

• Copy given to patient

Confident Smiles of Laurens318 FARLEY AVENUE i LAURENS SC. 29360 | (864)766-4633

Written Financial Policy

Thank you for choosing Confident Smiles of Laurens. Our mission is to serve the residents of the Upstate, educatingand empowering them to change their lives via a healthy, confident smile. An important part of our mission is makingthe cost of comprehensive care easy and affordable for our patients by offering several payment options.

Pavment Options:

You can choose from:

> Cash, MasterCard®, American Express®, Discover Card® orCareCredit®> Monthly Payment Options^ from CareCredit Healthcare Credit Card or our In-House Payment Plan (3 or

6 months) are also available

o Allows you to pay over time

o Interest Free Options

o No annual fees or pre-payment penalties

We require payment prior to the completion of your treatment. Ifyou choose to discontinue care before treatment iscomplete, no refund will be provided.

For larger, more comprehensive treatment plans of $1000 or more, a 10% deposit is required to secure your initialtreatment reservation.

We offer a 5% accounting courtesy adjustment to patients who pay for their treatment on or before the day ofservice with Cash for treatments of $1000 or more.

We also offer in-house financing for treatment plans between $500 and $7000.

A finance charge not exceeding 1.5% per month may be applied to that portion of the account balance not receivedwithin 30 days of receiving a mailed account statement from our office.

Please remember we are not party to the contract that is between you and your dental insurance carrier. Howeverwe are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for yourtreatment.^

A fee of $50 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.

Confident Smiles of Laurens charges $35 for returned checks.

Ifyou have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want orneed.

Patient, Parent or Guardian Signature Date

Patient Name (Please Print)

^Subject to credit approval

^However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatmentfees and collection of your benefits directly from your insurance carrier.

Medicaid Broken Reservation Policy

> Our office requires 48 HOUR notice if you are unable to attend your dental

reservation.

> We make multiple attempts to confirm your dental reservation. YOU MUST

CONFIRM YOUR RESERVATION. If your reservation is not confirmed 48 HOURS

in advance we reserve the right to give your reservation time away to another

patient.

Failure to give 48 hour-notice will result in the following:

1.) We will report your failed attendance to SC Medicaid—^WHICH MAY CAUSE YOU TO LOSE

YOUR MEDICAID INSURANCE!

2.) Patients who violate this policy 2 TIMES in a calendar year will be DISMISSED from our office.

Emergencies happen! We will allow special consideration for family emergencies (Ex. Sickness,Death in the Immediate Family)

Guardian/Patient Signature: Date:

Broken Reservation/Last Minute Cancellation Policv

> Our office requires 48 HOUR notice if you are unable to attend your dental

reservation.

> We make multiple attempts to confirm your dental reservation. YOU MUST

CONFIRM YOUR RESERVATION. If your reservation is not confirmed 48 HOURS

in advance we reserve the right to give your reservation time away to another

patient.

Failure to give 48 hour-notice will result In the following:

1.) A fee of $50 is charged for patients who miss or cancel more than 1 TIME in a calendar year.

2.) Patients who violate this policy 3 TIMES in a calendar year will be DISMISSED from our

office.

Emergencies happen! We will allow special consideration for family emergencies (Ex. Sickness,Death in the Immediate Family)

Guardian/Patient Signature: Date: