OFFICE & FINANCIAL POLICIES

Welcome and thank you for choosing the office of Todd H. Leiker, DDS. Please take just a moment to look over our office policies. We hope that by providing you with our policies in advance we can

prevent any misunderstanding or frustration at the time of your visit. Please feel free to ask us any questions you may have.

CHECK-IN: Be prepared to update any and all paperwork needed. Please bring your Driver’s License and current Insurance card with you at time of check in. This helps us keep our records current and helps us stop identity theft. Please don’t forget to give us your e-mail address or cell number if this is the best way to reach you. We use an automated service that calls, e-mails & sends text messages. All information is needed to help us help you.

CHECK-OUT: Please be prepared to pay for the current visit as well as any other past balances on your account. Payment of co-pays, deductibles or fee for non-covered services will be required at the time of service. For your convenience, we take cash, electronic checks; flex cards, debit cards and all major credit cards. Financing is available on amounts over $300! Just ask. Prior approval for financing is needed.

LATE ARRIVALS: We do our best to stay on schedule. If you arrive more than 15 minutes late, depending on your type of treatment and the amount of time needed, you may be asked to reschedule. Late arrivals can disrupt a whole day of scheduled patients. Please feel free to call us ahead of time and let us know if you will be late or ask if the doctor is running on time.

NO SHOWS: We require at least 48 hours advance notice if you must cancel /reschedule your appointment. For your convenience, we offer reminder e-mails and text messages, 7 days in advance, 3 days in advance and text messages 2 hours before your appointment. Conformation calls are also made 3 days before your appointment and can be done the day of if needed. NO SHOWS after a conformation has been made will be charged a no show fee of $150. If you cancel the day of your appointment a note will be made in your record. After three (3) cancellations or no shows we will ask that any future appointments be scheduled and secured with payment made at time of scheduling.

INSURANCE: We will gladly file your insurance claim and documents needed to get your claim paid for. We allow a time limit of 60 days from treatment to have insurance pay. After this time the full balance becomes the responsible parties/ patients and the insurance claim is closed. Patient is ultimately responsible for their account.

MINORS: The parent or guardian accompanying a minor child will be responsible for providing current insurance information and payment in full for services provided. Unaccompanied minors must have full payment for their visit that day, and a consent form from their parent to be treated.

DIVORCED PARENTS: We do not get involved in any disputes between parties. The parent accompanying the child will be responsible for providing current insurance information and any payment at the time of service.

I have read, understand and agree to the above office and financial policies. I hereby attest that I have given and agree to provide current demographic and insurance information. I authorize release of information necessary for insurance filing and pre-certification by signing this statement.

PATIENT NAME (PRINTED)__________________________________

SIGNATURE OF RESPONSIBLE PARTY: ________________________

DATE:____________________

Todd H. Leiker, D.D.S, P.A. 25412 I-45 North

Spring, Texas 77386

HIPAA Consent Form

Dear Patient, In accordance with the Health Information Portability and Accountability Act (HIPAA) instituted by the federal government on April 14, 2003, the physicians and/or staff of Todd H. Leiker, DDS are unable to release any information concerning our patients without their specific written consent.

I hereby authorize the physician and/or staff of Todd H. Leiker, DDS to release information pertaining to my condition, care and/or test results to the individuals listed below:

1._____________________________________________ ______________________________ (Name) (Relationship)

2._____________________________________________ ______________________________ (Name) (Relationship)

Primary Contact Information

_______________________________ _______________________________ ______ (Home) (Cell Phone) (Both)

Expiration Date of Authorization This authorization is effective indefinitely as of the date of signing this document unless revoked or terminated by the patient or patient’s representative. It is your responsibility to inform our office if you would like to make changes to this form.

Right to Terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Todd H. Leiker, DDS.

________________________________________ ________________ (Patient’s Signature) (Date)

_______________________________________ (Patient’s Printed Name)

If signature is not patient’s, please indicate relationship.

( ) Parent or guardian of minor patient ( ) Guardian or conservator of incompetent patient

Patient Registration

First Name: __________________________ MI: _____ Last Name: ____________________________

Birth Date: ___________________ Age: ________ Sex: Male Female

SS#: ____________________________ Drivers Lic: _______________________

Address: _________________________________________________________________________

City: _________________________ State: ______________ Zip: _________________

Home Phone: _________________________ Work Phone: _______________________ Ext: _______

Cell Phone: ___________________________ Pager: __________________________

Best time and place to reach you: ________________________________________________________

E-Mail: _____________________________________ I would like to receive correspondences via e-mail

Occupation: ______________________________________________________________________

Patient Employer/School: _____________________________________________________________

Marital Status: Minor Married Single Divorced Widowed Separated

PRIMARY DENTAL INSURANCE: (If Any Secondary Insurance, it must be filed by the patient)

Policy Holder: _____________________________________________________

Policy Holder’s DOB: ____________________ Policy Holder’s SS#: ____________________________

Relationship to Patient: __________________________ Employer: _________________________

Insurance Co. _________________________________ Group #: __________________________

Insurance Phone #: _____________________________ Coverage Active Since: _________________

IN CASE OF EMERGENCY CONTACT: (Someone not living in your household)

Name: ______________________________________ Relationship: __________________________

Home Phone: ______________________________ Work Phone: ______________________________

How did you hear about our Office? Internet Insurance Mini Implant Brochure

Lumineers Review It Magazine Neighborhood Newsletter

Drive By Interfaith Directory Dr. Leiker’s Website

Patient: _________________________________ Doctor: ______________________________

Other: __________________________________

Dental History Information

Reason for today’s visit: Exam Emergency Consultation

Do you have any dental problems now? Yes No If Yes, Explain:

___________________________

Are any of your teeth sensitive to: Hot Cold Sweets Biting or Chewing

PLEASE CHECK ANY OF THE FOLLOWING PROBLEMS:

Discomfort, Clicking or popping in jaw Lost or Broken Fillings

Stained Teeth Sensitive teeth or gums

Mouth odors or bad taste Loose teeth or Change in bite

Finger/Thumb Sucking Pain (in joint, ear, side of face)

Red, swollen or bleeding gums Speech Problems

Teeth Grinding Ringing in Ears

Bad Breath Locking Jaw

Blisters/Cold Sores in or around the mouth Broken/Chipped teeth

Other:__________________________________________________________________

Do you require pre-medication? Yes No Don’t Know

Previous Dentist: ________________________ Phone: ____________________ Last

Dental X-rays: ____________________ Last Dental Exam: _______________________

How often do you brush? ________________ Last Dental Cleaning: _____________________

How often do you floss? ____________________

What type of toothbrush bristles do you use? Soft Medium Hard

How would you rate you smile? 1 2 3 4 5 6 7 8 9 10

(Worst) (Best)

Todd H. Leiker, D.D.S, P.A. 25412 I-45 North

Spring, Texas 77386 (281) 363-0500

Informed Consent for Oral Cancer Screening

As a healthcare provider, I am concerned about oral cancer, which is too often diagnosed in later stages of development as a result claims more than one life every hour in America. It has become the sixth leading cancer among men and is one of the few cancers in which the rate of occurrence is increasing among young adults. Most people are not aware of the potential risks; however, when detected early enough, the survival rate for oral cancer is very high.

At one time oral cancer was predominantly seen among smokers, however, increasingly, oral cancer is being seen in patients of all ages. Although smoking is still a leading factor, many other criteria such as age, family history, ethnicity and alcoholic consumption also play a role. Many experts have surmised that an increasing cause is exposure to the HPV virus, which is the primary precursor of cervical cancer. There are 9,700 new cases of cervical cancer each year whereas there are 31,000 cases of oral cancer every year. Also, the morbidity rate of oral cancer is TWICE that of cervical cancer. These various factors all point towards the need for better technology to assist in early detection of this curable disease.

Here at our office, we have always conducted an annual comprehensive oral cancer screening for all of our patients, but we have recently incorporated a new FDA-approved breakthrough technology that will allow us to see things we’ve been unable to see previously. By detecting potential problems earlier, we’ll be providing our patients with the best oral health care currently available.

This new and exciting technology, called VELscope, utilizes a narrow band of safe, high-energy blue light and specialized filtering technology to help thoroughly evaluate the oral tissue for abnormal areas of concern, such as potentially cancerous lesions that may not be evident under white light. To get more information, you may visit www.velscope.com.

We care about your health as well as your teeth; we are now offering this to all adult patients during their oral examinations. We believe that this new technology will assist us in detecting this disease at an earlier stage and therefore catch abnormalities before they turn into cancer.

Your dental insurance may or may not cover the fee for this care. Coverage for this procedure (like most dental procedures) usually varies among insurance companies; however, this modest fee of $40.00 is well worth the benefit that this new technology provides.

Listed below are the leading risk factors associated with oral cancer. Please check below if any of the following apply to you:

____ Use of Tobacco Products ____ Family Members have had Cancer

____ Drink Alcohol ____ Over Age 40

____ YES, I would like to have the VELscope oral cancer screening test today.

____ NO, I would prefer not to have the VELscope oral cancer screening test today.

Patient Signature ___________________________________________ Date _______________

Todd H. Leiker, DDS, PA25412 I-45 NorthSpring, TX 77386

Date:_______________

PATIENT NAME:_______________________________________________ Birth Date:_________________

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationships with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician’s care now? Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?Are you taking any medications, pills or drugs?

Do you take, or have you taken Phen-Fen or Redux?Have you taken Fosamax, Boniva,Have you taken Fosamax, Boniva, Actonel, or any other

medications containing bisphosphonates?Are you on a special diet?

Do you use tobacco?Do you use controlled substances?

YesYesYesYesYes

YesYYesYesYes

NoNoNoNoNo

NoNoNoNoNo

If yes, please explain:____________________________________If yes, please explain:____________________________________If yes, please explain:____________________________________If yes, please explain:______________________________________________________________________________________________________________________________________________

Women: Are you Pregnant / Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No

Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs If yes, please explain: ___________________________________________________________________________________________

Do you have or have you had any of the following?AIDS/HIV Positive Alzheimer's Disease AnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart Artificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart Disorder Convulsions

Cortisone Medicine DiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pacemaker Heart Trouble/Disease

Hemophilia Hepatitis A Hepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid Disease Psychiatric Care

Radiation Treatments Recent Weight Loss Renal DialysisRheumatic FeverRheumatismScarlet FeverShinglesShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal Disease Yellow Jaundice

YesYesYesYesYesYesYYesYesYesYesYesYesYesYYesYesYesYesYesYes

NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo

If Diabetic, What is your A1C? ________ When was A1C last checked? ___________ What is your normal blood sugar reading?__________________

Doctors Name/Phone# ___________________________________

If you have Osteoporosis have you ever had a bone density test?___________________ If so, When & Results?_______________________

Doctors Name/Phone# ___________________________________ Have you ever used Botox/Fillers?_____________ How Long ago?__________________

Pharmacy/Location/Phone# _____________________________________

TTo the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN__________________________________________________ DATE:___________________________

YesYesYesYesYesYesYYesYesYesYesYesYesYesYYesYesYesYesYesYes

NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo

YesYesYesYesYesYesYYesYesYesYesYesYesYesYYesYesYesYesYesYes

NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo

YesYesYesYesYesYesYYesYesYesYesYesYesYesYYesYesYesYesYesYesYes

NoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoHave you ever had any serious illness not listed above? Yes No

Normal Blood Pressure reading?__________ Any allergies to metal?_____________

Do you snore or have you ever worn a CPAP machine? ____________________

Todd H. Leiker, D.D.S, P.A.ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES**You May Refuse to Sign This Acknowledgement**

I have read or received a copy of this office’s Notice of Privacy Practices.

{Signature}

{Date}

For Office Use Only

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 Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)