Dental History

Why have you come to the dentist today? _________________________________________

____________________________________________________________________________

____________________________________________________________________________

Are you currently in pain? ___Yes ___No

Have you experienced problems associated with any previous dental work? ___Yes ___No

Do you have frequent headaches? ___Yes ___No

Do you now or have you experienced pain/discomfort in your jaw joint (TMJ/TMD)?___Yes ___No

Your current dental health is: ___Good ___Fair ___Poor

Do you floss daily? ___Yes ___No Brush Daily? ___Yes ___No

Type of bristles on your toothbrush? ___ Hard ___ Medium ___ Soft

How long do you use a toothbrush before replacing it? _______________

Do you require antibiotics before dental work? __________________________

Do your gums bleed? ___Yes ___No Do they itch? ___Yes ___No

Have you ever had Periodontal Disease? ___Yes ___No

Does food get caught between your teeth? ___Yes ___No

Are your teeth sensitive to heat, cold or anything else? ___________________________________

Do you have any loose teeth? ___Yes ___No

Have you lost any teeth? ___Yes ___No

Are you happy with the way your smile looks? ___Yes ___No If not what would you like to change?

____________________________________________________________________________________

____________________________________________________________________________________

Who was your previous dentist? _________________________________________________________

When was your last visit at the dentist? ___________________________________________________

When was your last set of X-rays taken? ___________________________________________________

ESSEX DENTAL ARTS---PATIENT REGISTRATION

First Name:___________________________ Last Name:__________________________ Middle Initial:________

Preferred Name:_______________________

Address:_____________________________ City, State, Zip:____________________________________________

Home Phone:_________________________ Work Phone:___________________ Cell Phone: _______________

Sex: ○ Female ○ Male Marital Status: ○ Married ○ Single ○ Divorced ○ Separated ○ Widowed

Birth Date:_______________ Social Security #: ________________ Drivers Lic#:______________________

E-mail: _______________________________________ ○ I would like to receive email correspondences

Employment Status: ○ Full Time ○ Part Time ○Self Employed ○ Retired ○ Unemployed

Student Status: ○Full Time ○ Part Time

Preferred Pharmacy:______________________________ Referred By:_______________________________________

Emergency Contact:______________________________ Phone #: __________________________________________

Primary Insurance Information:

Name of Insured:________________________________ Relationship to Insured: ○Self ○Spouse ○Child ○ Other

Group Number: _________________________________ Insurance ID:___________________________________

Insured Social Security #: _________________________ Insured Birth Date:_______________________________

Employer:______________________________________ Insurance Company:______________________________

Address:_______________________________________ Address: _______________________________________

City, State, Zip:_________________________________ City, State, Zip:__________________________________

Insurance Phone Number:_________________________

Secondary Insurance Information:

Name of Insured:_______________________________ Relationship to Insured: ○Self ○Spouse ○Child ○ Other

Group Number: _______________________________ Insurance ID:__________________________________

Insured Social Security #: _______________________ Insured Birth date:______________________________

Employer:____________________________________ Insurance Company:____________________________

Address: ____________________________________ Address: _____________________________________

City, State, Zip:_______________________________ City, State, Zip:________________________________

Insurance Phone Number:________________________

Responsible Party: (if someone other than the patient )

First Name:____________________________ Last Name:__________________________ Middle Initial:________

Address:_______________________________ City, State, Zip:___________________________________________

Home Phone:__________________________ Work Phone:____________________ Cell Phone:_______________

Birth Date:______________ Social Security #:_____________________Driver Lic#:_______________________

○ Responsible Party is Policy Holder for Patient ○ Primary Policy Holder ○ Secondary Policy Holder

Relationship to Patient:___________________________

ESSEX DENTAL ARTS – CHRISTINE C. GRECO, DMD, PA 304 Bloomfield Ave. Verona, NJ 07044

NOTICE OF PRIVACY PRACTICES (effective date: 01/01/2015)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment, or healthcare operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you, examining your teeth, prescribing medications and faxing them to be filled, referring you to another doctor or clinic for other healthcare services, or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans or other sources of payment, preparing or sending bills or claims, and collecting unpaid amounts (either ourselves or through a collections agency or attorney). “Healthcare operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for healthcare operations are: financial or billing audits, internal quality assurance, personnel decisions, participation in managed care plans, defense of legal manners, business planning and outside storage of our records. We routinely use your health information inside our office for these purposes without special permission. If we need to disclose your health information outside our office for these reasons, we will not ask you for special written permission. We will ask for special written permission and abide by laws pertaining to applicable cases. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

when a state or federal law mandates that certain health information be reported for a specific purpose;

for public health purposes, such as preventing or controlling disease, injury or disability, reporting adverse reactions to medications or foods to the federal FDA, notifying a person who may have been exposed to or may be at risk for contracting or spreading a disease or condition

disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; uses and disclosures for health oversight activities, such as for the licensing of doctors, for audits by insurances, or for investigation of possible

violations of health care laws;

disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;

disclosures for law and enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime, or to identify or locate a suspect, witness, or missing person

disclosure to a medical examiner to identify a person dead or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;

uses or disclosures for health related research; uses or disclosures to prevent a serious threat to health or safety;

uses or disclosures for specialized government functions, for lawful national intelligence activities; for military purposes or for the evaluation and health of members of the foreign service;

disclosures of a “limited data set” for research, public health, or health care operations;

uses or disclosures to comply with worker’s compensation laws or similar programs that provide benefits for work-related injuries or ilnesses disclosures to “business associates” who perform healthcare operations for us and who commit to respect the privacy of your health

information Unless you object, we may also share relevant information about your care with your family or friends who are helping you with your dental care.

APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment remainder on a post card and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. We may initiate the authorization process if the use or disclosure is necessary on our end. Sometimes, you may initiate the process if it is your request for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing and sent to the office contact person named below.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION Access: You have the right to see or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.99 for each page, $50 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form. OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future, if we change our Notice of Privacy Practices, we will post the new notice on our office, have copies available in our office, and post it on our website: www.essexdentalarts.com COMPLAINTS If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. FOR MORE INFORMATION Contact officer: Christopher B. Greco Address: 304 Bloomfield Ave. Verona, NJ 07044 Telephone: 973-239-0032 E-mail: essexdentalarts@gmail.com

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Essex Dental Arts’ Notice of Privacy Practices.

Patient (or Guardian) Name ___________________________________________ Patient (or Guardian) Signature ________________________________________ Date _________________ For Office Use Only Received by:______________________________ Date:_______________ We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: ____Individual refused to sign ____Communication barriers prohibited obtaining the acknowledgment ____An emergency situation prevented us from obtaining acknowledgement ____Other (Please Specify):