Health & Happiness * Exceptional Dentistry

Welcome to our Practice

Thank you for choosing our office for your dental care. We are delighted to welcome you

to our dental family and appreciate the opportunity to provide you with the best quality dental care and a comfortable experience. Our goal is a long term relationship of dental care and commitment to your needs, as our valued patient.

To better assist you for your appointment we have enclosed information about our practice along with patient questionnaires to fill out. Please take a few minutes to complete the questionnaires and bring all the forms with you at your appointed time.

Please arrive 15 minutes prior to your appointment to check-in. We thank you in advance for honoring your appointment time. If you must cancel your appointment, we request the courtesy of 24 hours notice. If you are more than 10 minutes late, we will do our best to accommodate you, but your visit may have to be rescheduled.

Please don’t hesitate to call if you have any questions. We will call to confirm your appointment prior to the date scheduled.

Thanks again for choosing our office for your dental needs. We look forward to meeting you and providing you with exceptional dentistry in a caring environment. Sincerely,

Dr. Nicol R. Cook & Team

Map & Directions:

From Escondido and Points North Take Interstate 15 south and exit at Pomerado Road. Proceed about 4 miles to 15835 Pomerado Road, (just north of Pomerado Hospital). Turn left into parking lot at intersection of Bernardo Heights Pkwy. From Mira Mesa and Points South Head north on Highway 15. Take Camino Del Norte exit. Turn right. Proceed approximately 3 miles to Pomerado Road. Turn left and continue past the Pomerado Hospital to 15835 Pomerado Road. Turn right into parking lot at intersection of Bernardo Heights Pkwy. From Ramona and Points East Take Highway 67 to Poway Rd. Turn right on Espola Rd. Turn left on Twin Peaks proceed approximately 5 miles. Turn right on Pomerado Road to intersection of Bernardo Heights Pkwy. Turn right into parking lot at 15835 Pomerado Road.

Office Hours: Mondays: 8 am to 4 pm. Tuesdays, Wednesdays and Fridays: 8 am to 5 pm. Thursdays: 8 am to 12 pm.

Health & Happiness * Exceptional Dentistry

AbouttheDoctor

Dr.Cookisanexperienced,exceptionallytrainedandhighlyskilledprofessionalwhohasbeenpracticingtheartofdentistryforover25years.Withadvancedstate-of-the-artdentaltechnology,sheisabletoofferherpatientstodaymorechoicesoftreatmentoptionsthaneverbefore.Inthefastpacedenvironmentofimprovingdentaltechnologies,itrequiresspecializedtrainingandexceptionalprofessionalskillstoapplythemtoachievemaximumresults.Dr.CookhascommittedandestablishedherselfasbeingaleadingedgeproviderinAdvancedCosmeticandNeuromuscularDentistry.

Dr.NicolR.CookhasearnedthedesignationofFellowfromLVIGlobal,theLasVegasInstituteforAdvancedCosmeticandNeuromuscularDentistry,recognizedbydentistsaroundtheworldasthepremierpostgraduateinstitutionforcontinuingeducationinadvanceddentalstudies.

TheLVIFellowdesignationrecognizesthatadentisthascompletedaseriesofstudiesontheclinicalskillsandknowledgenecessarytoprovidecomprehensiveaesthetictreatmentforthedentalpatientastaughtinLVI’sCoreSeries.Dr.Cookhassetherselfapartbychoosingthepathoflifelonglearningandundergoingelective,continuoustrainingatLVI.Dr.CookhasexemplifiedadesiretomaintainthebestclinicalabilityinordertoofferahighlevelofAestheticNeuromuscularDentistry.ThisdedicationdistinguishesDr.NicolR.Cookbyprovingherdedicationtoqualityofcareandadesiretomastercomplexproceduresinordertoprovidethebestcomprehensivecareforherdentalpatients.

ProfessionalAffiliations:

MemberoftheAmericanDentalAssociation

MemberoftheCaliforniaDentalAssociation

MemberoftheSanDiegoCountyDentalSociety

MemberoftheAmericanAcademyofCosmeticDentistry

LasVegasInstituteforAdvancedDentalStudies-LVIFellow

Languages:FluentinEnglish,Spanish,Italian,andfamiliaritywithPortugueseandFrench.

Passionofcreatingsmiles

Herapproachtoyourtreatmentstartswithpatientlylisteningtoyourconcerns.Then,afteracompleteandthoroughexamination,shereviewsanddiscussesthediagnosisandtreatmentoptionswithyou."Iamproudtoprovidemypatientswiththeverybestindentaltechnology,treatmentoptionsandpatientcomfort.Itismypleasuretoaddressallyourquestionsandconcerns.Anewconfidentsmilechangesyourlife.Itismypassiontodesignandcreateasmilethatwillreflectyourpersonality,andprovideyouwithhealthandhappiness,throughexceptionalDentistry.”

Friendlyandcaringteam

Ourgoalistoprovidecompletedentalcarefortheentirefamilyinacomfortableandrelaxingsetting.Ourofficeprovidesaprofessionalandfriendlyatmosphere.Youcanrestassuredthatyou'llreceivethepersonalizedattentionyoudeserve.Earningyourtrustisthemostimportantthingwecanaccomplish.Takingthetimeonthefirstappointmenttogettoknowyouandyourprioritieshelpscreateopenhonestcommunicationsaboutyourdentalhealth.Ourteamofdentalprofessionalsisalwaysheretoserveyou.You'llenjoyourfriendly,caringteam.Ourpracticeprovidesthefollowingservices:

Ø CosmeticDentistryExtremesmilemakeovers,porcelainveneers,bonding,Zoom2-1hourIn-officeteethwhitening.

Ø RestorativeDentistryComposite(tooth-colored)fillings,inlays,onlays,crowns,bridges,implantsrestoration,partialdentures,fulldentures,anddenturerepair.

Ø PeriodonticsLaserGumtherapy,non-surgicalgumtreatment,ultrasoniccleaning,scalingandrootplaning,lasergumrecontouringandcrownlengthening.

Ø LaserDentistry.Softtissuediodelaser,cosmeticgumrecontouring,softtissuelesionremovals.Ø TMJTherapy

TENStherapy(TranscutaneousElectricalNeuralStimulation)musclerelaxationtherapyusingaTENSunit.TMJneuromuscularorthotics,nightguards,painmanagement,bruxism(grinding),athleticmouthguards.K7computerizedTMJscans.BiteOrthoticTherapy.

Ø NeuromuscularDentistryNeuromusculardentistryservestorealignthejaw,placingthejawinthemostrelaxedpositionwheretheteeth,musclesandjointsareinharmony,tostabilizethebiteandreliefsymptomsofTMJdysfunction.

Ø SnoringandSleepApneaTreatment Oralappliancetherapy,withamandibularadvancementsplint(MAS)ormandibularadvancementdevice(MAD)isacustom-mademouthpiecethatshiftsthelowerjawforward,openingthe airwayduringsleep.Ø Endodontics.RootcanaltherapyØ PreventiveDentistryfortheentirefamily Fluoridetreatmentsandsealantstopreventcavities.Ø Anesthesia-Sedation.Nitrousoxide(laughinggas),localanesthesia,andoralsedationdentistry.Ø OralSurgery.Simpleextractions,non-impactedwisdomteeth,andlaserfrenectomies.

TechnologyWeutilizethelatestindentaltechnologyinordertomakeyourappointmentaneasyandcomfortableexperience:

Ø LaserDentistryØ IntraoralcamerasforinstantviewingØ CosmeticimagingtopreviewyoursmileØ DigitalX-raysforyoursafety.Ø TENSTherapy(TranscutaneousElectricalNeuralStimulation)Ø Computer-AidedBiteEvaluationK7SystemforDiagnosisofTMJdysfunction.TMJcomputerizedscans:EMG(Electromyography),ESG(Electrosonography),CMS(ComputerizedMandibularScanning).Ø HomeSleepStudywithPortableMonitorMedibyteJr.

SterilizationTechniques

ü Ourstrictsterilizationprotocolsarejustasimportanttousastheyaretoyou.WeabidebyallOSHAstandards,andalsoutilizesporetestinginouroffice.

PATIENT QUESTIONNAIRE

This information is important for your dental care and will be kept confidential. GENERAL INFORMATION Date:_____/____/____ FINANCIAL INFORMATION

As a courtesy to you, our office will assist you in maximizing your insurance benefits; however payment of dental services is ultimately your responsibility.

Patient Last Name____________________________________________ First Name:__________________________ Middle:___________________ Preferred Name:_______________________ Date of Birth:_____/_____/_____ Age:_______ Marital Status:______________ � Female � Male Home Address Street:_______________________________________________ City______________________ Zip Code:____________________ How would you prefer to be contacted for appointments? Please check box. �Home Phone:(_____)___________________________________ �Work: (_____)________________________ �Cell: (_____)_____________________________�E-mail:____________________________________ Occupation:__________________________Employer:___________________ ____________________Social Security # :________________________ Spouse’s Name:______________________________________________________________________________________________________________ Spouse’s Occupation:_______________________________________ Spouse’s Employer:__________________________________________ Employer’s Address:____________________________________________________ Spouse’s Work Phone:_________________________________ Patient’s Medical Doctor’s Name:________________________________________________________________________________________________ Address:__________________________________________________________________ Phone:(______)______________________ Name of Former Dentist:__________________________________________________ Location:_______________________________________ When was last dental visit?___________________________________ For what purpose?________________________________________________ Chief complaint :______________________________________________________________ Date of last dental X-rays:______/______/_____ Emergency Contact Name:____________________________________________________ Relationship:________________________________ Address:____________________________________________________________________________ Phone # :(______)________________

Person Responsible for Payment:____________________________________________ Relationship to Patient:_____________________________ Address:___________________________________________________City_______________ Zip Code:____________ Phone:(______)___________ Primary Insurance: _________________________________________ Subscriber:________________________________________________ Social Security #:______________________ Date of Birth:_____/_____/_____ Insurance Company:_____________________________ Phone:(______)______________ Group #:______________ Employer:_________________ Secondary Insurance: Subscriber:________________________________________________ Social Security #:______________________ Date of Birth:_____/_____/_____ Insurance Company:_____________________________ Phone:(______)______________ Group #:______________ Employer:_________________ FINANCIAL RESPONSIBILITY I understand that I am financially responsible, whether my insurance company pays or not, for all charges incurred by me (or my dependents). I further agree that in the event of non-payment, I will bear the costs of collection and/or court costs and reasonable legal fees should such court action be required. I agree that a photocopy of this authorization shall be valid as the original. SIGN NAME:_______________________________________________________ DATE:_______________________________ Authorization for Signature on file and Consent for Release of Information to Insurance Company I hereby authorize Dr. Nicol R. Cook, DDS,APC to bill my insurance company directly, to receive payment from the insurance company on my behalf, to furnish any information necessary to complete and/or settle my dental claim.

SIGN NAME:_______________________________________________________ DATE:_______________________________

I have received a copy of the Dental Materials Fact Sheet. I have had the opportunity to read it and discuss the information with my dentist prior to placement of further dental restorative work. SIGNATURE:______________________________ DATE:____________

I have received a copy of the Notice of Privacy Practices dated April 14, 2003 from Dr. Nicol R. Cook, DDS, APC. SIGNATURE:______________________________ DATE:____________

HOW DID YOU HEAR ABOUT OUR OFFICE? �Family member or friend:_____________________ � Insurance Co:_____________________ �Google � Other internet source________________ � Direct Mailer � Dr. Cook’s Website � LVI Website � Angie’s List � Referred by Dr. ___________________ � Other_____________________

MEDICAL HISTORY CONDITION YES NO CONDITION YES NO

AIDS/ HIV Immunodeficiency Disorder Heart Surgery/ Pacemaker Allergy to Latex Hepatitis Type: / Liver Disorder/ Jaundice Allergic to medications: HPV (Human Papilloma Virus) Anemia High Blood Pressure Arthritis Intestinal problems/ Colitis Artificial joint replacement (e.g. hip) Surgery date: Kidney Disease/ Bladder problems Asthma Major Surgery Blood Disease Mental / Nervous Disorders/ Psychiatric Problems Bleeding/ Clotting Disorder Personal History of Periodontal Disease? Cancer Pneumonia Chronic Bronchitis Radiation or Chemotherapy for tumor Diabetes Respiratory problems Drug Abuse Rheumatic Fever Emphysema Scarlet Fever Epilepsy/ Seizures Sinus problems Female: on BCP? Smoker/ Tobacco use Female: Nursing? Stroke/ Brain injury Female: Pregnant? Due date: Stomach problems/ Ulcers Glaucoma Thyroid problems/ Goiter � Hypo � Hyper Hay fever/ seasonal allergies/ nasal allergies Tuberculosis Heart Attack Stents placed Venereal Disease Heart Murmur/ Mitral Valve Prolapse Herpes/ � oral � genital

Are you currently under the care of a physician? YES____ NO____ Physician’s name:______________________________________________________ Phone:___________________________ Reason:____________________________________________________________________________________

Are you currently taking any drugs or medications? Specify name and dose:_________________________________________________________________ Any OTC meds? Herbal supplements?:______________________________________________________________________________________________

Have you ever taken bisphosphonate drugs either intravenously or pills, such as Fosamax, Aredia, Boniva, Actonel, Zometa, Ostac, Didronel, or Skelid, for treatment of osteoporosis or bone cancer? YES____ NO____ Specify: _______________________________________________________________

Is there any other condition (s) or disease that the doctor should be aware of?_______________________________________________________________

Family History of Heart Disease, Diabetes or Periodontal Disease?

DENTAL HISTORY YES NO YES NO Is there anything about the appearance of your teeth you would like to change? Specify:

Do you have a consistent problem of food caught between your teeth??

Have you ever had any popping or clicking sounds or pain in TMJ joints?

Do you have snoring problems? Do you have sleep apnea? Stop breathing at night?

Do you clench or grind your teeth? Day____ Night_____ Do you have hot and cold sensitivity? Do you have facial pain, muscle fatigue or jaw pain? Do your gums bleed when brushing or flossing? Do you have neck aches, shoulder aches or cervical tension? Have you ever been treated for gum problems? Do you have any back pain or other joint problems? Have you ever had a problem with a dental procedure? Do you ever have any headaches? Area:_______________ How often are they:

Have you ever had orthodontic treatment (braces)? When? _______________For how long? ______________

What can we do to make your stay more comfortable?

What are your goals for your long term dental health?___________________________________________________________________________________ _____________________________________________________________________________________________________________________________

LATECANCELLATIONPOLICY:Anyappointmentsmissedorcancelledwithin24hourswillbechargeda$50cancellationfee.BysigningIacknowledgethispolicy. Signed:_______________________________________ Date:______________CONSENT I hereby authorize the treating dentist to perform necessary dental procedures on the above named patient. Such treatment may include but is not limited to: examination, radiographs, oral impressions, dental restorations, oral surgery, administration of anesthetics, analgesics, antibiotics, and sedatives. I further state that the medical and dental history was fully and accurately completed to the best of my knowledge. Signed:______________________________________________ Date:_______________________ Relationship to patient:____________________________

PREMED NEEDED YES NO

MUSCULOSKELETAL –OCCLUSAL SIGNS EXAM FORM

Name ____________________________________________ Date______________ Age_______ Please only check the symptoms section 1 to 22. (not the signs section)

Symptoms o 1. Headaches o 2. TMJ Pain o 3. TMJ Noise o 4. Limited Opening (Occlusion) o 5. Ear Congestion o 6. Dizziness (Vertigo) o 7. Ringing in the ears (Tinnitus) o 8. Difficulty Swallowing (Dysphagia) o 9. Loose Teeth o 10. Clenching / Bruxing o 11. Facial Pain o 12. Tender Sensitive Teeth o 13. Difficulty Chewing o 14. Cervical Pain o 15. Posture Problems o 16. Tingling in fingertips o 17. Sensitive Teeth (Hot and Cold) o 18. Facial Nerve Pain (Trigeminal

Neuralgia) o 19. Bell’s Palsy o 20. Nervousness o 21. Insomnia/Snoring

Signs Extra-Oral (For Doctor Use Only)

o 1. Facial Asymmetry Bilaterally o 2. Short Lower Third of the Face o 3. Chelitis o 4. Abnormal Lip Posture o 5. Deep Mentalis Crease o 6. Dished-Out or Flat Labial Profile o 7. Facial Edema o 8. Mandibular Torticollis o 9. Cervical Torticollis o 10. Forward Head Posture (Lordosis) o 11. Elongated Lower Face (Steep

Mandibular Angle) o 12. Speech Abnormalities

Signs Intra Oral (For Doctor Use Only) o 1. Crowded Lower Anteriors o 2. Wear of Lower Anteior Teeth o 3. Lingual Inclination of LowerAnteriors o 4. Lingual Inclination of Upper Anteriors (Div. II occlusion) o 5. Bicuspid Drop Off o 6. Depressed Curve of Spee o 7. Lingually Tipped Lower Posteriors o 8. Narrow Mandibular Arch o 9. Narrow Maxilary Arch ( High Palatal Vault) o 10. Midline Discrepancy o 11. Malrelated Dental Arches o 12. Tooth Mobility o 13. Flared Upper Anteriors o 14. Facets o 15. Cervical Erosion o 16. Locked Upper Buccal Cusps o 17. Fractured Cusps (particularly Cl. I & II non functional cusp) o 18. Chipped Anterior Teeth o 19. Loss of Molars o 20. Open Interproximal Contacts o 21. Unexplained Gingival Inflammation and Hypertrophy o 22. Crossbite o 23. Anterior Open Bite o 24. Anterior Tongue Thrust o 25. Lateral Tongue Thrust o 26. Scalloping of the Lateral Borders of the To

15835 Pomerado Road, Ste. 202 Poway, CA 92064

PLEASE HANDLE ME WITH CARE! So we can better serve you, please check mark next to the statement that concerns you or describes your problem. Patient name: _______________________________________

o I gag easily

o I have back problems and can’t lie down fast or all the way.

o I have vertigo and can’t lie down all the way.

o I don’t like shots, I have fear of needles.

o My teeth are very sensitive.

o I want to know about the treatment, please explain procedures.

o I don’t want to know about the treatment, please don’t explain procedures.

o I hate the noise of the drill.

o I prefer headphones with relaxation music

o I prefer no anesthetic for dental procedures.

o I prefer extra anesthetic for dental procedures.

o None

o Other ________________________________________________________________

_______________________________________________________________________