Welcome to our office!In order to serve you properly, we will need the following informotion (pleose print)

All informotion will be kept strictlv confidentiol

Potient Informotion ond HistoryA, Potient Nome Lost: First : Mi. :

(lf P,O. Box, pleose give street oddress olso)

f E Moritolstotus

Home Phone # [

Emoi lAddress @

Employe/s Nome or School

Closesi Relotive (not living with you)

Nome Phone #

Emergency Contoct (other thon spouse)

Nome

lnfOfmOtiOn (checkirsomeosobove) tr Sociol Sec,#

Nome of Responsible Porty D,O,B. Drivers Lic. #

EmoilAddress

Work Phone ( ) Cell Phone t )

Employe/s Address

Employe/s Phone

C, PCnlment InfOfmOtiOn Poyment ond/or verificotion of insuronce coveroge is required ot the time oftreotment to cover your portion of fees not covered by insuronce, We occept the following poyment opiions, Pleoseindicote your choice[s) of poyment, We ore hoppy to onswer ony question you moy hove.

I Cosn I Cnect f, Credit Cord ! Finonce Compony

lf you hwe dentol insuronce, p/eose fill-ln the following informsfion:

Primory Insuronce Secondory InsuroncePolicv Holde/s Nome Policy Holde/s Nome

Nome of Insuronce

Phone( ) Group#

SS # DOB

D, Referrol! Insuronce Compony

f Rotient:

! wott<-in

Who moy we thonk for referring you?f] Vettow Poge Ad

! Physicion:

! Postcord or Moil Piece

I Sign i Billboord

! Newspoper (specifyl:

I otner:

E, Poyment & Treotment Consent I outhorize the doctor to toke x-roys, study models, photogrophs orony other diognostic oids deemed oppropriote by the doctor to thoroughly diognose dentol needs ofI olso outhorize the doctor to perform oll recommended treotment mutuolly ogreed upon by me ond to employ such ossistonceos required to provide proper core, I give my consent to use locol onesthetics, reloxonts, onolgesio ("loughing gos"), ontibiotics, orpoin medicotion if deemed necessory for the completion of ony dentol treotmeni, I understond thot the use of onestheiic ogentsembodies o certoin risk. I olso understond thot responsibility for poyment for dentol services provided by this office for myself or mydependents is mine, due ond poycble of the time services ore rendered unless other finonciol orrongements ore mode, In theevent of defoult, | (we) promlse to poy interest ot the rote of 1 5% monthly on the indebtedness, together with oll collection costsond reosonoble otlorney fees os moy be required to effect the collection of this note, FEES NOT PAID BYTHE INSURAI\ICE COMPA,I{|WITHIN 60 DAW N?E PAYABIE FROM THE PATIEM OR THF RESPONSIBIE PN?N.

Signolure of Responsible Pody X Relotionship to Potient: Dote;

F. AUthOfiZOtiOn I hereby outhorize my insuronce benefits to be poid directly to the docto/s office ondolso outhorize the doctor to releose ony informotion to process insuronce cloims,

Dote Signoture {insured} X

Dote Signoture (potient or guordion) X

G. Dentol Services Acknowledgement

I . I understond ihot whenever o tooth is extrocted, there is o possibility of infection, bone frocture, tempororyporesthesio (numbness) of the lip, gum, tongue ond/or fociol skin, lt is possible, olthough rore, thot the poresthesiowould be permoneni,

2. I understond thot root conoltreotment is on ottempt to retoin o tooth ihot would otherwise require exlroction,Although root conoltreotment hos o high degree of success, it connot be guoronteed, Occosionolly o ioothundergoing root conoltreotment moy undergo ocute infection. li moy require re-treotment, surgery, or (rorely)extroction.

3. I understond thot preporotion of teeih for crowns, bridges, ond fil l ings moy, on occosion, troumotize the pulp(nerve). lf the pulp (nerve) is in o weokened condition, this moy necessitote o root conoltreotment on thot tooth inthe future.

4, I reolize thot dentol insuronce policies restrict poyment for some services, use restricted fee schedules (colledUsuol ond Customory Rotes) ond exclude some procedures bosed on prior conditions or length of time on plon,Posterior teeth moy be poid for ot "silve/'or omolgom fill ing rote, All restrictions ore bosed on the premium poid forinsuronce ond not our fees or recommended treotment.

5. Women toking birih control pills should be owore thot ontibiotics, such os penicill in or erythromycin, couldpossibly counteroct the effects of the pill ond you could become pregnont,

A I raatiza thnt nn,/ of the work thot the doctor proposes con be performed by o speciolist, I will tell the doctor orhis stoff if I desire thot o speciolist perform the work,

7. I do / do not (circle one) gront permission to toke photogrophs of my mouth or heod ond neck to used, withoulreveoling my identity, for the furthering of medicolond dentol knowledge ond educotion.

B, I understond thot if I foil to give o 24 hour notice to concel o scheduled oppointment I con be chorged o feeup io the omounl of the scheduled oppointment procedure, I olso understond thot ony X-roys token ore property ofthe dentist, ond ihot o fee moy be chorged for ony duplicotion or tronsfer of soid X-roys, I hove not token ony moodor mind oltering drugs prior to signing this form,

Dote Signoture X

Patient Name DENTAL HISTORY

Patient Acct. # Medical Alert

Welcome! So that we may provide you with the best possible careplease complete both sides of this medical/dental history form.

All information is completely confidential.

What is the reason for your visit today?

Date of Last Dental Visit Last Dental Cleanins Last Full Mouth X-rays

What was done at your last dental visit?

Previous Dentist's Name:

Address State zip

Telephone

How often do you have dental examinations?

How often do you brush your teeth? How often do you floss?

What other dental aids do you use? (Sonicare, toothpick, etc.)

Do you have any dental problems now? Yes No

If yes, please describe:

ARE ANY OFYOUR TEETH SENSITIVE TO HAVE YOU EYER HAD:Orthodontic treatment?Oral Surgery?...Periodontal treatment? ........Your teeth ground or bite adjusted?...........A bi te plate or mouth guard? . . . . . . . . . . . . . .A serious injury to the mouth or head?.lf so, please describe. including cause_

.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .yes

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .YesNoNoNoNoNoNoNoNoNo

YesYesYosYesYesYes

NoNoNoNoNoNo

Bit ing or Chewing?.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes

Have you noticed your mouth odors or bad taste?...........Yes

Do you frequendy get cold sores, blister or any otler lesions?.Yes

Do your gums bleed or hurt? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .YesHave your parents experienced gum disease or tooth loss?.YesHave you noticed any loose teeth or change in your bite?.Yes

Does food tend to become caught in between your teeth? Yes HAVE YOU EVER EXPERIENCED:Clicking or popping of the jaw?.. ...........Yes NoPain? (oint , ear, s ide of face). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes NoDifficulty in opening or closing the mouth?....................Yes NoDifficulty in chewing on either side of the mouth?..........Yes NoHeadaches,neckachesorshoulderaches?.. . . . . . . . . . . . . . . . . . . . .Yes NoSore muscles (neck, shoulders). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes NoAre you satisfied with your teeth's appearance?..............Yes NoWould you like to keep all of your teeth all of your life?Yes NoDo you feel nervous about having dental treatment?.......Yes No

If yes, Where?

DO YOU:Clench or grind your teeth while awake or sleep? Yes

YesYesYesYesYesYes

NoNoNoNoNo

NoNo

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth?.........(penci ls, p ipe, p ins, nai ls, f ingemai ls) . . . . . . . . .Mouth breathe whi le awake asleep?.. . . . . . . . . .

Have tired jaws especially in the morning?

Smoke/Chew tobacco?.. . . . . . . . . . .If so, what is your biggest concem?Have you ever had an upsetting dental experience?........YesIf yes, please describe

Is there anything else about having dental treatment that you would like to know?If you could have a magic wand and change anything about your smile, what would it be?If yes, please describe

(Please complete other side)

Patient Name MEDICAL HISTORY

Patient Acct. # Medical Alert

Have you been under the care of a medical doctor during the past two years? ..... Yes NoIf yes, for what?Physician's NameAddress

PhoneCity State Zin

Have you taken any medication or drAre taking any medication, drugs, or

ugs during the past two years? Yes No

If yes, please list name and dosageAre you aware of having an allergic (or adverse reaction) to any medication or substance?..................Yes NoIf yes, please list:Have you been a patient in the hospital during the past five years? ........ ...........Yes NoIndicate which of the following you have had, or have at present. Circle "yes" or "no" to each item.

Have you lost or gained more than l0 pounds in the past year? Yes NoDo you have or have you had any disease, condition, or problem not listed? Yes NoIf yes, please list:Women: Are you: Pregnnnt? Yes, - Month No Nursing? Yes No Taking birth control pills? Yes No

I understand the above information is necessary to provide me with dental care in a safe and fficient manner. I have answeredall questions to the best of my knowledge. Shouldfurther information be needed, you have permission to ask the respectivehealth care provider or agency, who may release such information to you. I will notifu the doctor of any change in my health ormedication.

P ati ent/ G uardian Si gnature X

History Review

Doctor Signature Date

Heart (Surgery, Disease, Aftack).Yes No

Chest Pain . . . . . . . . .Yes No

High Bktod Pressure . . . . . . . . . . . . . . . . . . .Ye" ' No

Art hr i t i .s / Rhe urnat is m . . . . . . . . . . . . . . . . . . .Ye s N o

Cort isone Medicine . . . . . . . . . . . . . . . . . . . . .Yes No

Swollen Ankles . ..Yes No

Stroke . . . . . . . . . . . . . . . . .Yes No

Diet (Special/Restricted) .............Yes No

Kidney Trouble. ..Yes No

U\cers. . . . . . . . . . . . . . . . .Yes No

Diuheles . . . . . . . . . . . . .Yes No

T hyroid Pro b Ie mr. . . . . . . . . . . . . . . . . . . . . . . . .Ye s N o

Gluucotna.. . . . . . . . . .Yes No

Cqntact Lenses. ..Yes No

Emphyserna...... ..Yes No

Chronic Couqh.. . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes No

Tuberculosis ..... ..Yes No

Asthemu.. . . . . . . . . . . . .Yes No

Hay Fever. . . . . . . . . . .Yes No

Faint ing or Dizty Spe l ls . . . . . . . . . . . . . . . . . . . . . . Yes No

N ervous/ AnxiouJ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ye s N o

P sychiat r ic/ P syco lo g ical C are.............Yes N o

Prosthet ic Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes N o

Infect ive Endocardi t is . . . . . . . . . . . . . . . . . . . . . . . . . .Yes N o

Valvulitis as a result oJ a lrdnsplanl ....Yes No

Congenital Heart Disease or Defect:. Unrepaired Cyanotic Congenital

Hectrt Disease .......Yes No. Palliative Shunts or Conduits.........Yes No. Completely repaired congenital heart

dekct with prosthetic material or device

placed by surgery or cathzter during

the rtril 6 nnnrhs after thz procedure..Yes No. Repaired congenital heart disease

with residual defects at the site or

adjacent to the site of a prosthetic

pdtch or prosthetic device which

inhi bits endo t he lializution...............Yes N ct

Date

Notice of Privocy Proctices Acknowledgement(HtPPA)

I understond thot, under the Heolth Insuronce Portobiliiy & Accountobility Act of I 996 ('H|PPA"), I hovecertoin rights to privocy regording my protected heolth informotion, I understond thot this informotion conond will be used to:

o Conducf, plon ond direcf my freafment ond follow-up omong the multiple heollhcore providerswho mov be involved in fhof treotment directlv ond indirecflv

o Obtoin poyment from fhird-porty poyers.

o Conducf normol heolfhcore opero/ions such os quolily ossessmenfs ond physicion certificotions,

I ocknowledge thot I hove received your No/lce of Privocy Procfices contoining o more completedescription of the uses ond disclosures of my heolth informotion, I understond thot this orgonizotion hosthe right to chonge its No/ice of Privocy Proctices from time to time ond thot I moy contoci thisorgonizotion of ony time o the oddress obove to obtoin o current copy of the Notice of Privocy Proctices,

I understond thot I moy request in writing thot you restrict how my privote informotion is used or disclosedto corry out treotment, poyment or heolthcore operotions, I olso understond you ore not required to ogreein rnrr ranr racior{ ,oStriCtiOnS, bUt if yOU dO Ogree then yOU Ore bOUnd tO Obide by SUCh reStriCtiOnS,,v, , ,y,v\- lvve,vv,v\

Potieni Nome

Responsible Porty IPrint) Relotionshio to Potient

Signoture of Responsible Poril X Dote

FOR OFFICE USE ONLYI ottempted to obtoin the potient's signoture in ocknowledgement on this Notice of Privocy Proctices

t. but wos unoble to do so os documented below: