Chris L. Lewis, D.D.S.P.O. Box 660 Livingston, TX 77351 (936) 327-2151 (936) 327-8012 fax

Patient InformationPatient's Name:Preferred Name:SSN: Birthday:Responsible Party (ifpt is minor):Relationship to patient:Address:City: -Home #:Email Address:Marital Status:Emolovment Information:Present Occupation:Years Employed:

Sex:

State:Work #:

Zip:Cell #:

Dental HistoryReferred by: -Previous Dentist:Date of last check up/ teeth cleaning:What do you like about your smile?What is your main concern? -On a scale of 1-10 (10 being highest) how important is it for you to keep your teeth for therest of your life?

Insurance InformationIns Co. Name:Ins Co. Address: ""

Ins Co. Phone #:Employer:Group #:Subscriber Name:Subscriber SSN:

Relationship:Subscriber B' day:

I have provided accurate information on this document and will be responsible to updateToday's Dental of any changes. I authorize the release of information for insurance purposesand give consent for treatment to Dr. Lewis and staff. I understand photographs may be takenand used for education and advertising purposes.

Signature: Date:

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Chris L. Lewis, D;D.S.P.O. Box 660 Livingston, TX 77351 (936) 327-2151 (936) 327-8012 fax

Responsibility and Consent StatementResponsible Party:

Please complete the following infonnation. Responsible party can not be a minor.Person responsible for the account:Relationship to the patient:Address:City, State, Zip:Employer: -Occupation:E-mail Address:

Driver's License #Home phone #:Birth Day:Work phone #:SSN:

Consent:I hereby authorize and request the perfonnance of dental services for myself or

. I also authorize the dentist, Dr. Chris Lewis, to perfonn any advisabledental diagnostic procedures, and provide any medications and treatment as may benecessary to make a thorough diagnosis of my or my dependent's dental needs.

I authorize release of any infonnation concerning my or my dependent's healthcare,advice and treatment provided for the purpose of evaluating and administering claims forinsurance benefits. .

I authorize the release of any infonnation concerning my or my dependent's healthcare,advice and treatment to another dentist.

I authorize payment of insurance benefits directly to the dentist, otherwise payable to me.

I understand and acknowledge I am financially responsible for the services provided formyself or my dependent for payment in full on all accounts, regardless of insurancecoverage.

Patient or Responsible Party Signature Date

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Statement of Privacy PracticesOur office is dedicated to protect the privacy of our patients and the confidential information that you haveentrusted to us. The commitment of each employee to ensure that your health information is nevercompromised is a principle concept of our practice. We may, from time to time, amend our privacypolicies but we will always inform you of any changes that may affect your rights.

Protecting Your Personal InformationWe use and disclose the information we collect from you only as allowed by the Health InsurancePortability Act and the State of Texas. This includes issues relating to your treatment, payment, and dentalcare protocol. Your personal health information will never be otherwise given to anyone, even familymembers, without your written consent. Of course, you may give written authorization for us to discloseyour information to anyone you choose, for any purpose.~'

Collecting Protected Health InformationWe will only request personal information needed to provide our standard of quality dental care, implementpayment activities, conduct normal dental practice operations and comply with the law. This may includeyour name, address, telephone #, SSN, employment information, medical history, health records, etc. Whilemost of the information will be collected from you, we may obtain information from third parties if it isdeemed necessary. Regardless of the source, your personal information will always be protected to the fullextent ofthe law.

Disclosure of Your Protected Health InformationAs stated above, we may disclose information as required by law. We are obligated to provide informationto law enforcement and governmental personnel under certain circumstances. We will not use yourinformation for marketing purposes without your written consent. We may use and or disclose your healthinformation to communicate reminders about your appointment including voice messages, answeringmachines and postcards.

Patients RightsYou have the right to request copies of your healthcare information; to request copies in a variety offormats; and to request a list of instances in which we, or our business associates, have disclosed yourprotected information for uses other than stated above. All such requests must be in writing. We maycharge you for your copies in the amount allowed by law. If you believe your rights have been violated, weurge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

Printed Name:

Signature:

Date: