COVID-19 QUESTIONNAIRE

PATIENT DI S C LO S U RE S : Patient Name Edmund Sun Birth Date 05/22/1987

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.

Yes No
Do you have a fever or above normal temperature?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Have you experienced shortness of breath or had trouble breathing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Do you have a dry cough?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Do you have a runny nose?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Have you recently lost or had a reduction in your sense of smell or taste? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Do you have a sore throat?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Have you been in contact with someone who has tested positive for COVID-19 in the past 14 days?. . . . . . . . . . . . . . . . . . . . . . o ✔
o
Have you been tested for COVID-19 in the past 14 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
If so, date of test and have you tested o Positive o Negative o Awaiting Results
Have you traveled outside the United States by air or cruise ship in the past 14 days?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
Have you traveled within the United States by air, bus or train within the past 14 days?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o

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 which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

X X X 11/11/2024
Signature of patient (Parent or Guardian if Minor) Reviewed by Date

COVID-19 PANDEMIC DENTAL TREATMENT

NOTICE AND ACKNOWLEDGMENT OF RISK FORM

The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are
aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be
highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any
place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is
an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the
COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as
your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control,
universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing
between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during
the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

X X X 11/11/2024
Signature of patient (Parent or Guardian if Minor) Doctor Date
 Welcome to our Practice
PATIENT I N FO R M AT I ON: Today’s Date 11/11/2024
✔ Mr. ❏ Mrs. ❏ Ms. ❏ Dr. First Name Edmund
❏ M.I. Last Name Sun
Sex: ❏ Male ❏ Female Birth Date 05/22/1987 Age 37 Soc. Sec. #
069-96-7840 sunedmund@icloud.com
E-mail
Street 685
brookside ct Apt. City Westbury State NY Zip 11590
Home Tel.( 646 ) 861-9805 Cell.( 646 )
861-9805 ✔ No
Have you ever been a patient of our practice? ❏ Yes ❏
East meadow dental associates
Referred By ✔ No
Has a family member ever been a patient of our practice? ❏ Yes ❏
FIRST NAME LAST NAME

Dentist Klein Orthodontist

FIRST NAME LAST NAME FIRST NAME LAST NAME

Aleyamma
Medical Dr. Jacob Rite aid
Preferred Pharmacy Tel.( 516 ) 876-0592
FIRST NAME LAST NAME

Driver’s Lic.# 505853988 Nearest relative not living with you

Chengwei Hou Tel.( 646 ) 867-5656
FIRST NAME LAST NAME

Employer Bank of America Merrill lynch Bus. Tel.( 201 ) 557-4238 ✔Credit Card
Personal Payment Type: ❏ Cash ❏ Check ❏
Xiaotong chen
In case of emergency, please contact Tel. ( 347 ) 264-6899 Relation Spouse
WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT:
✔ Self (If self, skip this section) ❏ Spouse ❏ Father ❏ Mother ❏ Other
❏
Name Edmund Sun S.S.# 069-96-7840 Birth Date 05/22/1987 Age 37
FIRST NAME LAST NAME

Tel.( 646 ) 861-9805 Cell. ( 646 )

861-9805 E-mail sunedmund@icloud.com
Street 686
brookside ct Apt. City Westbury State NY Zip 11590
505853988
Driver’s Lic.# Bank of America Merrill lynch
Employer Bus. Tel.( 201 ) 557-4238

S POUSE O R O T HE R G UA R A NT OR INF ORM AT IO N: (IF D IFFER EN T FR OM A B OVE)

Name
FIRST NAME LAST NAME
Relation S.S.# Birth Date
Street Apt. City State Zip
Tel. ( ) Employer Bus. Tel.( )

I NSURA N C E I N FO R MAT ION:

Student:. . . . . . . ❏ Full Time ❏ Part Time ✔ Not. . . . . . . . . . . . School Name and Address
❏ SCHOOL NAME ADDRESS

Marital Status:. . ❏✔ Married ❏ Divorced ❏ Widow ❏ Single ❏ Legally Separated CITY STATE ZIP
✔ Full Time
Employed: . . . . . ❏ ❏ Part Time ❏ Retired ❏ Not. . . . . . . . . . . . . . . . . . . . . . . . . Do you belong to a PPO or HMO? ❏ Yes ✔ No
❏

P RIMA RY DE N TAL I NSUR A NC E COM PA NY: PR IM A RY M ED IC A L INS UR A NC E C OM PAN Y:

Employer Tailwind capital Employer Bank of America Merrill lynch
Bus. Address Bus. Address
ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP

Bus. Tel.( 201 ) 557-4238 Plan MetLife Bus. Tel.( 201 ) 557-4238 Plan
MetLife
Ins. Co. Name I.D. # 069967840 Ins. Co. Name I.D. #
Address Address
ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP

Tel.( ) Group Name Tel.( ) Group Name

Group # Insured Party Edmund Sun Group # Insured Party Edmund Sun
FIRST NAME LAST NAME FIRST NAME LAST NAME

Relation 05/22/1987
Birth Date ✔M ❏ F
Sex: ❏ Relation 05/22/1987
Birth Date Sex: ❏ M ❏ F
069-96-7840
S.S. # Tel.( 646 ) 861-9805 069-96-7840
S.S. # Tel.( 646 ) 861-9805
686 brookside ct
Address ADDRESS Westbury NY 11590 686 brookside ct
Address ADDRESS Westbury NY 11590
CITY STATE ZIP CITY STATE ZIP

S ECONDARY DE N TAL INSUR A NC E COM PA NY: S EC OND A RY M ED IC A L INS UR A NC E C OMPAN Y:

Employer Employer
Bus. Address Bus. Address
ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP

Bus. Tel.( ) Plan Bus. Tel.( ) Plan

Ins. Co. Name I.D. # Ins. Co. Name I.D. #
Address Address
ADDRESS CITY STATE ZIP ADDRESS CITY STATE ZIP

Tel.( ) Group Name Tel.( ) Group Name

Group # Insured Party Group # Insured Party
FIRST NAME LAST NAME FIRST NAME LAST NAME

Relation Birth Date Sex: ❏ M ❏ F Relation Birth Date Sex: ❏ M ❏ F

S.S. # Tel.( ) S.S. # Tel.( )
Address ADDRESS CITY STATE ZIP
Address ADDRESS CITY STATE ZIP
 Patient Name Edmund Sun
HEALTH HI S T O RY:
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you
may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you
for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today’s office visit? Tooth extraction

Yes No
1. Height 6 feet 1 inchWeight 195 pounds Are you in good health?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ✔
o o
2. Have there been any changes in your general health in the past year?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
3. Are you under the care of a physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of last visit o ✔
o
If so, for what are you being treated?
4. Have you had any illness, operation or been hospitalized in the past five years?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
If so, describe
5. Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?. . . . . . . . . . . o ✔
o
If so, describe where
6. Do you have a prosthetic joint / implant?. . . . . . . . . . . . . . . . . . . If so, describe where o ✔
o
7. Have you had a heart valve replacement or vascular graft?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
8. Have you ever had general anesthesia?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ✔
o o
9. Have you, or a family member, had any unusual or serious reactions to general anesthesia? . . . . . . . . . . . . . . . . . . . . . . . . o ✔
o
10. Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? . . . . . . . . . . . . o ✔
o

HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE: YES NO NOTES HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE: YES NO NOTES
11. Rheumatic fever? ✔ 39. Convulsions / epilepsy? ✔
12. Damaged heart valves / mitral valve ✔ 40. Stroke? ✔
prolapse?
41. Thyroid trouble? ✔
13. Heart murmur? ✔
42. Diabetes? ✔
14. High blood pressure? ✔
43. Low blood sugar? ✔
15. Low blood pressure? ✔
44. Kidney trouble? ✔
16. Chest pain / angina? ✔
45. High cholesterol? ✔
17. Heart attack(s)? ✔
46. Are you on dialysis? ✔
18. Irregular heart beat? ✔
47. Swollen ankles / arthritis / joint disease? ✔
19. Cardiac pacemaker? ✔
48. Osteoporosis / osteopenia? ✔
20. Heart surgery? ✔
49. Osteonecrosis? ✔
21. Pneumonia, bronchitis, chronic cough? ✔
50. Stomach ulcer / acid reflux? ✔
22. Asthma? ✔
51. COVID–19? ✔
23. Hay fever / sinus problems? ✔
52. HIV? ✔
24. Snoring? ✔
53. Contagious diseases? ✔
25. Sleep apnea / CPAP? ✔
54. Sexually transmitted diseases? ✔
26. Difficult breathing / other lung trouble? ✔
55. Problems with immune system?
✔ ✔
27. Tuberculosis? Possibly from medication / surgery, etc.
28. Emphysema? ✔ 56. Autoimmune disease? ✔
29. Do you smoke or vape? ✔ 57. Delay in healing? ✔
If so, how much a day
58. A tumor or growth? ✔
30. Do you use chewing tobacco? ✔
59. Cancer / radiation therapy / chemotherapy? ✔
31. Blood transfusion? ✔
60. Chronic fatigue / night sweats? ✔
32. Blood disorder such as anemia? ✔
61. Are you on a diet? ✔
33. Bruise easily? ✔
62. A history of alcohol abuse? ✔
34. Bleeding tendency / abnormal bleed? ✔
63. A history of marijuana or other drug use? ✔
35. Hepatitis, jaundice, or liver disease? ✔
64. Contact lenses? ✔
36. Infectious mononucleosis? ✔
65. Eye disease / glaucoma? ✔
37. Gallbladder trouble? ✔
66. Mental health problems / anxiety /
✔ ✔
38. Fainting spells? depression?
67. A removable dental appliance? ✔
68. Pain or clicking of jaws when eating? ✔
 Patient Name Edmund Sun
WOMEN O N LY: ( Q UES T ION S 6 9 – 7 2 )
Yes No Yes No
69. Is there a possibility of pregnancy?. . . . . . . . . . . . . o o 71. Are you nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . o o
70. Expected delivery date? 72. Are you taking birth control pills?. . . . . . . . . . . . . . . o o
Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

ARE YOU NOW TAKING: YES NO NOTES ARE YOU ALLERGIC TO, OR HAD A REACTION TO: YES NO NOTES
73. Any kind of medication, drug, pills? ✔ 81. Local anesthetic (numbing meds.)? ✔
74. Blood thinners (Coumadin, Plavix, 82. Penicillin? ✔
Aspirin, Vitamin E, Ginko biloba, ✔ 83. Other antibiotics? ✔
Aggrenox, Xarelto, Eliquis, Fish oil)?
84. Sulfa drugs? ✔
75. Have you ever taken diet pills? ✔
85. Sodium pentothal / Valium /other tranquilizers? ✔
76. Any natural product, herbal
✔ 86. Aspirin?
supplement or homeopathic remedy? ✔
77. Are you taking, or have you ever taken bone 87. Amoxicillin? ✔
density meds, RANKL inhibitors or bisphos- 88. Codeine or other narcotics? ✔
phonates such as Prolia, Fosamax, Boniva, ✔
Actonel, IV-Zometa, Aredia, Reclast, Xgeva, 89. Latex? ✔
or Evista in the past 12 years? 90. Soy? ✔
78. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a 91. Eggs / yolk? ✔
regular basis? If so, please list:
92. Sulfites? ✔
93. Do you have any known allergies? ✔
79. If you are under the care of a physician for pain management, or
recovering from drug addiction please select the medication you 94. Please list any allergies other than drug allergies:
are currently taking: o Methadone o Suboxone o Oxycodone
o Fentanyl o Other
Treating doctor:

80. Please list any medications you are currently taking:

Medication Dosage Frequency
Ursodial 6mg Twice per day

95. Please list any other medication or antibiotic you are allergic to:
Medication / Antibiotic Name

Is there a family history of:

o Cancer o Diabetes o Heart disease o Anesthesia problems

If you are having surgery today, have you had anything to eat or drink
in the last 6 (six) hours? ❏ Yes ✔
❏ No
Who is driving you home? Xiaotong chen

Is there any condition concerning your health that the Doctor should
be told about? ❏ Yes ✔ ❏ No – If Yes, describe

Do you wish to speak to the Dr. privately about anything? ❏ Yes ✔

❏ No
 Patient Name Edmund Sun

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my
satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

X X 11/11/2024 X X
Signature of patient (Parent or Guardian if Minor) Date Reviewed by Date

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office
manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have
any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay
fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any
other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

X X 11/11/2024
Signature of patient (Parent or Guardian if Minor) Date
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits
otherwise payable to me.
X X 11/11/2024
Signature of patient: (Parent or Guardian if Minor) Date

AUTHORIZATION
I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning.
Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any infor-
mation acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile
phone concerning my appointment

o I permit the office to communicate with me via text message on my cell phone.

X X X 11/11/2024
Signature of patient (Parent or Guardian if Minor) Doctor Date

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any
questions I may have regarding this Notice.

X X 11/11/2024
Signature of patient (Parent or Guardian if Minor) Date

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