Chart #: FORO-=-F=--E U"""--ON ­F1C"'"' SE"':'"- LY

Street

City

Patient Information

First

Stale

Apartment #

Zip Code

Health Information

Date of Last Dental Visit: Reason for this visit:

Have you ever had any of the following? Please check those that apply: o AIDS 0 Epilepsy o Kidney Disease o Allergies 0 Excessive Bleeding o Liver Disease

o Fainting o Mental Disorders o Glaucoma o Nervous Disorders

o Anemia o Growths o Pacemaker o Arthrit is o Hay Fever o Pregnancy o Artificial Joints o Head Injuries Due date:-----­D Asthma o Heart Disease o Radiation Treatment o Blood Disease o Heart Murmur o Respiratory Problems o Cancer o Hepatitis o Rheumatic Fever o Diabetes o High Blood Pressure o Rheumatism o Dizziness o Jaundice o Sinus Problems

• Do you have any drug allergies?

• Have you had any joint replacements. jf so which joint and whe n?

_

o Stomach Problems o Stroke o Tuberculosis o Tumors o Ulcers o Venereal Disease D Codeine Allergy o Penicillin Allergy OTHER: 0 _

0 _

• Please list any medications you are currently taking : (if need more space please either attach a copy or list on backside of paper)

Signature of patient, parent or guardian

Referral Information

Whom may we thank for referring you to our practice? DAnother patient, friend Danother patient, relative

o Dental Office o Yellow Pages o Newspaper o School o Work o Other

Name of person or office referring you to our practice:

Spouse or esponsible Party Information The following is for: o the patient's spouse o the person responsiblelor payment

Name: DMaie o Female o Married DSingle DChild o Other

Social Security #: Birth Date:

Phone (Home): (Work): Ext: Best time to call:

Address: Street Apartment #

C'ly Stale Zip Code --Employment Information

The following is lor: o the patient o the person responsible for payment

Employer Name: Occupation:

Address: Street Cil y State Zip Cone

Insurance Information

LaSI MI 10 # : _

S\,eet Stale Zip Code

Insured's EmployerName:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~_

Address : '~~~=-:--~~~~~~~~~~~~~~~~~~~~--=-~~~----=:""""'=--,-~~~_ Street City State

Patient's relationship to insured: 0 Self 0 Spouse 0 Child 0 Other _

Insurance Plan Name and Address: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~_

onsent for Services The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services. or any dental services performe d. must be paid for In full at the time services are performed.

Patients who carry dental insurance understand that all dental services fumished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the forms necessary so the patients may independent ly file claims so that he or she may be reimbursed directly by Insuance Company. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that the fee estimate listed for this denta l care can only be extended for a period of THREE months from the date of lhe original patient examination was performed.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assigne e. at the time said services are rendered. I further agree that a waive r of any breach 01any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attomey fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient. parent or guardian

Signature of guarantor of payment/responsible party

Myles F. Sadler D.D. S.

Acknowledgement Of Receipt Of Notice Of Privacy Practices

I have received a copy of this offices Non e of Privacy Prac tices .

Print Name

SIgnature

For Our O ffice Use Only

Our office attempted to obtain written acknowledgem ent of receipt o f Our Notice of Privac y Pr act ices, but acknowled gement could not be obtained for the following reason-

Patient refuse d 10 SIg n

Communication barr iers pr ohibited obta ining the acknowledgement

___ Ao emergency situation p revented us from obta ining acknowledgement

_ _ _ Other (Desc ribe below)

Myles F. Sadler D.D.S.

This Notice Q( Priv3CY Pract ices ocscribcs how We 1m)' me and disclose your tectcd h Il.l . r . . r ' pro ell 1 unorrnsnon 10 amy 0 111 trc armcm I

Op=!l<l >nd , 01 other P" fJ>OS~ thar nrc p=nc..:l or re:.nnirr.d by Js w I I alao -' h __ • I . - .. fl3ymcnr or ica lth care . -, "-'" UG>'-I "->0. y Olll n g .1> (0 ' 'CCeS! and con tro l your ed h

rnformeuon We an: req u ire d by Fe-dera l law to give von d l i: No ric , Hlld rn mam .~ : _ th e n ri I h lib _ , pmlc.et c.aJth ~ -- ". ~, e p n v JU:)'0 your Cll mform llOOll. We m usr I ''-'<1 1

le I of th i, 1'100 ' < Wfu lc " " IV effect. We reserve th" ricbt to chau .., ' . > " a so """ e 'Ythe . ' ' . 0 r,e III pr " llC) p n lr.l:u:= Hr", the- V on ", of tim ' "NO()ce e t nny r i mt Bdo ,c w e nak

~ I gn l li r.no( d LilJl!;c:. In our po v,.<:)'pnetlce:; we will change zhis N once "n O make " .. N ' I I I I e• ~ •. - .. _ .• w . new ouce zva, a I e upon r<:<jUe..sL

Yo u wi ll tx ,",l: C{j , iDl r.j , AcltJI~lT l ed f.~ e D ( ?1 Reecipl 0 1 Noc k . 01 r n v" CJ }', ac UCt'" O nce y o u h -r received our No tice o f rnv"ey P, =tlccs . dcidosure 01 yow pmr ccted h~Th information 'Wlll be used for trearrn eru, pa yment and h c.alch CUe opera tions, Yuur protected he a lth inforro:lIio o IDllYL<

us ed mil tfucl o~~d lJy OW O]jIC< s ta f] ~ld orbc:z curside uf OUT office Ihal IlIT rnvolved rn YO\.U OJe en d l""'lInenl for the purpo.e of pTOvidmg h<:al d , '",," c servic es to yO Il. \' o ur protected hc:tl th in fo rmation lD.l:.y a lso 1Jcn sed and d ,r.c)o.<;ed 10 p"y yOUT health c om : billJ "nd Co =pport dIe operati on of the o ur pm clIC"_ F. llowmg are examples o t th e types OfWCb nod di:>cl=un: ~ 0 1 r OUT pro tected b=Jdl <.:JUT Ullol1naDon Ih zl uur office is permrncd (0 make

Tro(lIltnr: We WIll useand d isclo se y our protected health informsuo« .n olba cicntim and pby~ , c".u.l-C provide.. coortlinsre, cPt manage your hc."\ld, ca re. 1'0' CJJ>1llpk, you. 1" ,nect.e<lI'c;;i.llh inion:ox.tio<! In")' be pro v io ed Iv 2 00 1h ", dclltll' 10 w hom you hnve been referred 10 ensure lhal th e nCCCS:r>l 'Y

UlfcTflu aoon n llv:ai lob lc 10 d' 3l: Il0~ r or treat yuu. In Illidilion. We 1ll1l)' dl., df~~e yo ", h""W. in fosm ati on nt u rncs kJ z dcnl'l.l hborzlO:y or apcciahst,

P Jl ~<ll t Yow prolect ed h allh info rmation w ill be 'used to obtain p o r ro c n l for services we pro v'd<: 10 you This DlR)' includc certUn 3CDVlO"" thaJ you l ~rJ(.~ pl t .n rn2 Y I m d e.rt.al:: r: bc fcr c it ::'P tJ"E l1VC~ or p:.t)'3 l or d l C S,C1 "VIC C." \\'1:' r e cornn s cnd ,

o c,oI1 hall t 0 I l .,. ti9~ 'Wt" In:oy us c UI discloae, your prutccrzd h eal rl.l mturr nlUlo ll III urUa 111 ~U "p O' 1 UK I" " ' II=.' ucti vi tics of our pracnce. These nCUVltlC' l/1d uGe;. lml llIc nol lmutcd to. quali cy ass= = l oct iY'llC!.. c mployee 1'"Cl.i<:w nctj-vilJa., 1t=1Iif~ t;l['.dcnti"l i nf~ Jl.Cl iyj li e,. e-o u l1lJc tmg lJlull i,. ~;

""d omcj, ' ctinc o th er hu:; mcss "-CtJ\· JI ,ClI. For CXJl1T.lple, we ron)' ' l.~ <: " (;1!1,ll-m . hc ct xl the regl Smuio ll dcl w he,,: yuu willlx: ~j to ..gu Y0ul JUlInC . nd u>d,C"(e yom doom, We m"y u40 c.nIl you by n:uDe in Ihe W1Ilrng m um wtlC1l )'\Jor doaor j,; ,,,,,,, Iy Co """ )"UU. We IIUl)' usc 0 , dir.c10-x )'Olll pm,cetC(\

ba lch mJ o:mRllOn. I ll eca::>. Il.I)" . 10 com .a.cl you 10 n:mind you or Yl nll ~1'1",lJ lI 1Jl Cl ' 1.

B u sin cs s As:loda (es : W ..."-i ll dU<T!= y our prou:etul ht".Rllb inf9f1Il1l ti o ll \VIII. third p"' ly n\ L~in e_,,, AJ;socunc lhAt-PCI:(o n u v mio"-" ",a ivin"" ( hilli nl flr_ IZl b<.1 rnto q ' frJv1CO) fa T rh c pr.~ eric e \V}\Cnr.veI Jtn mnmgClllClJt l)CtW t':O l u m ntfi.e:o Ilnd .n bw; incr..c. 115~· (J ci lU C ill,"olv4::Eii d JC usc l)r dlld (J~un:: o f )' ~Jtu

P10 ICac\"1 b ' llJth u l f o lT u ;>.tlon . we wi l l h~ \'c ,II "wri tten COD rract n UT C O O h l ll l; tnn l::> r:hnJ w il l p rlJ (cet r1l(' J" T" llC) ' u r ) T I\1f protected h eaU}, J11f o r n lAflo tl

'."C ID,' ) \ l.5t. 01 d1sclo ~c ) ' lJUI p, o to:tco h e r-lih In fu null1iOll, r. u c.~!.lJI Y. tu prov id e you w ut iuJonunuon r.OOUJ ~lncn ~ Jl)r~(]vc..s o r oLba bc:aJlh

r cl o l c.ti IJc I1t' h n .\TId :!>c rvu:-t:'"..,j, Ih a.l fn ay 0(' o f i n t crr_~ to y o u.. ' Ve ' TIll)' 1J \"''' 1 11 ":.1"" l'..ntj (h5.c lo ~ e )"'{)1.11 J1Jot.c.ctcd ile.:..h h InfD'T"IDJlOo n fOI otbo rnnr t. c:u n t ;l..C O Vl ti

FOI '=""' ft.!ll1l k-:, · \ U O IlJU l l C ~n c1 Add(~ rI'\.Ly be n~ cd 10 ~c-1) d yuu on nf;\...·.,.It"nn n \ l(wI1 rn lf JlT1'ctiCCl llf)(, t h e. Z;~ce.3 ,~ () O r:::( We omy 2l.1$o ~cn d y ou _ u l f Oi m a h Ou o u l pt'l) '~I1 ( 'l '1:.]' 1 ~ t_T''' l _r~ ehn, "IN'C. b elieve JD b) ' lx: h e n ri., In ' ' ''' you Y('J\) w,,;y c::ont ftC1 al ff I ln ....'lU,/ nlll.C1 to ~c.st 0-. ::11 t1 w:~ C' m :::\l.n"l t.h o o t

b e J,CD ' In yuu.

n~ t' :' . n ~1 UbcJo.\urC:J uf Pl"Otccted Bt:'..1l.1th Infornl:ltion llct:d U P OIl )'tUlf \V d U C-:D AuU..lO ri L.-.tJo n

ur Oll! nl) t.c:et..e(~ hcclth informat ion -wiJ1 he m.."1l k o n ly w ith you!" wl ll1c n .Il lthom .zti on.. unl~_ ortlC:::r"......i~cJ,e:m-l iw..d 0' Jl:ql~u Cl I , 01100 m CJ Il1ldrt15c1osur= Y I . . , ' r" ac 1)( 10 11>" =tcn.l1.:.t m IT prnctJCC 1= lllTC3dy tRb :r, an xco oo d . try law "" d::sm bcd lJ<:llYW 'y o u m ay t evoke this 1Ulthon:z.allou. :l1 Jlo)' Ill ll '- , m Wll mf.. e

pTov 'd~d lOT ill t.bc l\U(h l1J"ll..bDOn

MAd e ' Vllb Your Co",cn!. Jl lItl,o r i:tJId o n orOppol"t\Jnif)' I<, Ollj ecl U lllt. P e nnilled 1l"d R ...qu in ·,j U Sc:.'> .... nd Dlsdosu"" Th'" M By 1\.

. h 'ed III 111< 1l >C OT d j,;cJO SUlt ~ . ' f U .".r\n ins (~ nttS "YOlt ha,'( 11],(: 0PJ)ortu ull y 10 .H1 ~TtC or 0 ~

\).1< Ill" . ll'oe nnod1>c1u,,:: y o ur prOl ecl e d b""ld, infu lln et'Otl In th e 0 ~ g b1 t ' - or 0 \;)' e e l 10 the mt or ,\.isclusurc of the " m l<>: tcd he..all!> _~ 1 J b . If tio H you 1ITC " 01 pJ - en' <If» e II "lV"" . ty h< le<:led h=l!hof JLj1 (.II p ;u l u f YQUJ IH Ul r:Cl cu 'I e.:: 1. U o rm r. n. . 1 ~ 11 w sc1o"'ure i~ i u YQ Ul \x;.:. , in(cn:::~.l Ll1 ti n s ~c... on 1 1'1 0

~ nJ O rTIl :1n OD. lh en we ln ay . \B ing, p r ofc:ss ~onnl j\ld~C:OL..Oct.enn lll (' '" 1('1 .cr \0 J

I 10 rt1l3,1100 ' \17.1 IS u:lcvz.n' 10 )'o u! h eallh c>'Je WIll be disc1 o'-C<l

. , 1 ' 1 ' A r d AU VCl. I , clOSt friend or =y otbc:I p cr.;OIl yo u .de noly. ~ 0Ul F Am ily a nd Friend " tJnk, ~ y ou object, we mny di5 cl o se t O ll ID.elI.b t : ..~ ~~=~;~h po ymen ' for yOUl h=ltb=n:, W .....i~1 dso ~< I)UI l'.o l~ ...~n" l

,caw hcuch inforro" tiO ll I I) Ihc =I( ncee'","'Y ' 0 help l:'lIh ) o UJ h -d fill ed pR5cril'0 ol e . dcr.r.rJ suppho. >.-n,Y' 0 1 o llie< ~unJW p I ,al.c rc n.sonll, b lc dec; ion:s in )"("ltU hcst i n rcJ"C"'. ~ In a ll o 'ww r ~ penon to I11: . u p l J lll1 &J D l:Il1 0 m ~

fo ntU o f 1 1~ Lh i n ronn"h(~l

U 1I1/'l f'1'l1lJ1t\tf) :lind Requlrrd U.c> ,",d J) heln. " r " 'I'll , ! rvL ry n.· I'1 n ll < 'WIll", ... \ ' " " , ~ " ,,,e lll

E.m c.!J:~I~9: We (luy u sc or disclosc y o ur protected he?I I/1 inrormn no» III JIi CI1lClgcncy ( ,. /111011 si tua tio n. If l/lir happc.m, IV ' WlII trv ' 0 oOI<,io your A <.I" l{' lv \ eJl;~mell r o r Rec e ip r Of Notice O f J" ;YDey Prac rice» as , o cm :or reason a bty p eRn ,o l!;1 a l\ o the dd ivo y 0 1 l1r.n l m <:n t In lJ" cv r-u t 01 you l

on""I'" r iry or RII emergency, we will di sclose IICJIlth i n forma ti on ba$aJ on Jl rlctcrmimJli fll l lI" inl,' our l" ufe.ss iUflaljuog mw' dixlos i" f, on ly l.c.l lh 1111," '111,11" " 'hRI i. d irectly rd CV-oUll 10 the p enon' , inv olvemen t iT' r ou, hea lth (." C,

b~ ' r. (2.Lf.'i.r~ W e mHy d i,c!ose you, hC1,llh infor mation 10 "1'1l,ujl". le authorines if we J"",,;'o ,, nb ly Le lie-ve th a t y nu Ref " po svib le ' ~l Ii" , o f :" "Jf:~ uq;lrc i 0 1 d fHn~sric. v io le nc e': OJ th e p O I;.Eil ll (' v icti m or other cr imes We rnnv d i llc \( Jf.t: y()UI " a.lrh I n ! on n.:i.. hOl) to th e extern n eces s a ry 10 .f\Vl';rl, f,r..no u ~

vl rr c a t ItJ VOUI h C2 U l OJ r:d c t)' CIt l.he h c.all.h 4lnd safe ry o f ol:h~J :' . ­

J;>l lll.!.'U.y cltvil)" :.. ,d ti " 110 1lUI S ~cu dl Y; Wc may di..~d os c 10 rn il il>ty ~lI lllon l i c5 Ih e "callI, u.Iomiatio » 0 / Armed Forces p ccson ncl l ll llk ' U l l~ l fl n rcu n ,..m nr-eJ; \VC JTu y clisc lo se 10 ;u ILh oriz.ed fed eral uffi c i:d! hc·:d O. In Iorr ru noo rcq u rred for b ".dl.l l in1d Ii1.c:ncc...cO Lnl fmnlcH i g t::.Jlf"; ("" 8 J1d (10'0 fH l h o n JlI

"n~ ll n t \" .l C 1' V l l lc;, W e: ITl.."Jy d i:;cl osc to c.on ection.:U in s tiur tions or Ia w (7lf() J(.(,:fTw:n t u I1ICI;I!:-. hsl .... m ) ~ luwfu l c ustody, th e p ro tc..c icd h {':'"..l Hh .nlon na l lOB o r 1 1I 1J 1 .qr ~, ' n p~ 1I(,_ fl t5 un d er ccn niu ci rcu msn m cez. .

I lo-q lli ' ~ I,1 tho " n d. n i 5 ~Q611a.s ; U nd o the lxw, we n urst makz t1' M; lm UTr.1l 10 pw unll wh cn : q u n cd bj' the Sc;a r.I" ry ollhc [Jc p aJl;!TlCl II (I f Hc.aJ1.l1,,"d I I." rJ,il l . · n' fi~ 10 1(rV~LJga lc m dcl cn f U Ii C n U J 4 ;OJl lpl i."ln(.~ f"_

Y.!!.lI ~I~" l!!.uiJ:!lUQJ.r.!l'p " C{ ami (".l) v ' 11 lrolcc lc d he HI . . lirri;'c-.Q o- cr~J1 l io l a . Yoo ,n."1.yrc{~ &, I CSI d I .d . '-:" n(QrJUJlUOO_ 'You have Ule nglH 10 Jool '21 or f,c1 COJl f~ or yot,flltc-n ll h m fUI 11 JAl i or. , \O"jlh 1"; 'c t..- ;,1I) 11., :,..0 'Y ou rnus t lTl:Il -t

O . ) lIt we S ~HlV I • ~ COp ies m ~ fo r m a t n rho than p ho ro c o p iec '\V.: l.vi lJ ulle th e format y o u n::qOCSI ~ J nJ.c-...!. ~ VVY C;C111l 0 !

'. - I'C ' ("qU~.·' f rn ' '''nllog lo Ohf11111 o,rr r..s I ' J ! I . Ii " . I'nnbcf nd"fJnu :o. ljU J1 li s ted .at Ule: c:n rl ....frlll So lJ 1 • W .. .. - J, U l o ur IC-n 1 1 In ormatro n, I OU rnn yob rai n '" Iorm m rt"q \JCSI .:a Ll:~ by l15J1J ~ Ihe.

I. " ( n c r , e ~' III ci uu I'C YOll ~ rr-i!;o""h l • 11 L d f r ) . . n ..0 I-': (Jllt:"'. ~l Qcq: l.S Ly sen d Ing us ~ lCUo- to tI dd -' , . C co -n asr- rec OJ expenses l:UC 1 H ~. COpte:, 2.nd ~ 1a1 1 I l l n t: Yo u H l:IY IC II ress III th e " ,, 01 o f III N r If -' .

u , ln n l L;H Jfl tl (PI' ;. ICc. ~ . 11. (1 ICG. )"'OU Ph:Je'I . v-e ,vlnprepare 11 !. IHl u n ID )' 01 an c...q.r.};an ~. t H H l o r y o ur hca HJ--1o

\' '' l) :, ve II I ri ' h {01'" C UCJ;t 11 I Ill fo n nlltlOn by n11Cn1ntivc.17 ;J. crnJ.! t (: (, ~ ll lJ n ll n l c .nt lo H 3. fro l l) u \ _ Yell! h~ y C d lr- II ,1 r . 10 • •""fI . "lid proY;,lc ~a ti r.[; 7 ~ In n 1lc::n:; IIl'C; /oca lio q s,,)',," m"S) "'" ~ c Y CQ ' :_ .1 In ' ''' l Ih a l we c ocnmllJlIC81c WJUI yo u :11)0 .11 \~ ll ll heal l!1

J1S lll ll ''''~ '' ''•• • , ,,; 0 1)' ' :Jq ll:m n Uo lI ho w JU_Ymcnl> ,,,, II t ~ I . 11 '1 ri ' " e~ In ''''''JIll YUlII l r:fJ lI C.~111lUS·1 ~pet:ify the nJ'('rm l l VC 11 'Crill.\.0 1

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J anuary -J 2 , 006

7<1"1' /;0 " " : __ 0..Q§-7 92-4 4 64