This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition) can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

I fully understand and acknowledge the above information, risks, and cautions regarding a compromised immune system

and have disclosed to my provider any conditions in my health history that may result in a compromised immune system. By signing this document, I acknowledge the answers I have provided above are true and accurate.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but it is not mandatory for me to sign in order to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly

• Obtain payment from third-party payers
• Conduct normal healthcare operations such as quality assesments and dental certifications as well

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent.

I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time at the above address to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time except to the extent that you have taken action relying on this consent.

Thank you for choosing True Oral, Facial & Dental Implant Surgery as your trusted oral surgery provider. Your dental health is very important to us. Please carefully read over our office policies listed on this form. If you have any questions, please ask a staff member upon check-in or by calling our office.

• The patient or legal guardian is responsible for co-payments and co-insurance at time of service.

• The patient or legal guardian is responsible for deductibles, non-covered services, and amounts that the insurance denies, regardless of the reason. Please become familiar with your insurance benefits prior to services being provided.

• The patient or legal guardian will be held financially responsible if the insurance is not in effect at the time of the visit.

• If there is a balance on your account, you will be sent a statement to the mailing address on file. If payment has not been received within 90 days of the first billed date, the account will be sent to our collection agency.

• If the patient is a minor, whoever signs this form will be held financially responsible. No exceptions.

• In divorce situations, financial responsibility will be with the guardian/parent that signs for the minor child. We will NOT invoice the absent parent. Payment in full will be required before the time of surgery date.