Drs. Helsby and McMann 2100 AlomaAve., Suite 200 Winter Park, Fl

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1 2100 AlomaAve., Suite 200 Winter Park, Fl PATIENT REGISTRATION First Name: Preferred Name: Birth : City, State, Zip: Home Phone: _ Drivers License # Last Name: Middle Initial Patient is: Policyholder Responsible Party Soc Sec: Drivers License: Address 2: Work Phone: Ext Cell ^ Employer:. Employer _ Emergency Contact: Emergency Contact #: Sex: Male Female Marital Status: Married Single Divorced Single Separated Widowed Whom may we thank for referring you: Responsible Party (if someone other than the patient) City, State, Zip: ^ Address 2: Home Phone: Work Phone: Ext CelL Drivers License # ^ INSURANCE INFORMATION.Patient is Policy Holder Responsible Party is Policy Holder for Patient Name of Insured: Insured Soc Sec: Employer: Address 2:. Relationship to Insured: Insured Birth : Insurance Company:. Address 2:_ Self Spouse Child Other City. State, Zip : ^ City, State, Zip: Phone #:

2 Time 2:20 PM Patient Name: Drs Helsby And McMann Eaglesoft Medical History Birtli ; Created: 9/25/2017 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 talcing, could have an important interrelationship with the dentistr/ you will recede. Thank you for answering the following questions. Are you under a physician's care now? Yes No If ves Have you ever been hospitalized or had a major e Yes No If yes operation? Have you ever had a serious head or neck injury? 0 Yes No If yes Are you taking any medications, pills, or drugs? e Yes No If yes Do you take, or have you taken, Phen-Fen or Redux? 0 Yes No If yes Have you ever taken Fosamax, Bonlva, Actonel or Yes No If ves any other medications containing bisphosphonates? Are you on a special diet? Yes No Do you use tobacco? Yes No Women: Are you... G Pregnant/Trying to get pregnant? Nursing? DTaklng oral contraceptives? s Are you allergic to any of the following? C Aspirin [j Penicillin Codeine H Acrylic B Metal O Latex Sulfa Drugs H Local Anestfietics j Other' B If yes ' [ Z2 Do you use controlled substances? Yes No If yes ], Do you have, or have you had, any of the following? AIDS/HIV Positive Yes No Cortisone Medicine Yes No Hemophilia Yes!)No Radiation Treatments., Yes _ No Alzheimer's Disease Yes Mo Diabetes Yes IJo Hepatitis A Yes No Recent Weight Loss Yes No Anaphylaxis Yes No Drug Addiction Yes No Hepatitis B or C Yes : No Renal Dialysis O Yes No Anemia ' Yes No Easily Vi/inded Yes,} No Herpes Yes No Rheumatic Fever C' Yes O No Angina O Yes. No Emphysema Yes No High Blood Pressure Yes No Rheumatism C Yes No Arthrltls/Gout Yes cr No Epilepsy or Seizures Yes No High cholesterol Yes _ No Scarlet Fever C-' Yes O No Artificial Heart Valve / Yes e No Excessive Bleeding ' Yes ;j No Hives or Rash Yes DNo Shingles Yes No Artificial Joint Yes </_ No Excessive Thirst Yes J No Hypoglycemia Yes No Sickle Cell Disease = Yes C No Asthma ) Yes r No Fainting Spelis/Dlzziness Yes O No Irregular Heartbeat Yes No Sinus Trouble Yes No Blood Disease :> Yes C) No Frequent Cough ) Yes No Kidney Problems Yes No Spina Bifida Yes No Blood Transfusion Yes No Frequent Diarrhea Yes /'No Leukemia Yes : No Stomach/Intestinal Disease O Yes No Breathing Problems Yes No Frequent Headaches.. Yes ' No Liver Disease Yes J No Stroke ;> Yes No Bruise Easily ' Yes c! No Genital Herpes Yes No Lov/ Blood Pressure Yes No Sv/elling of Limbs Yes "No Cancer Yes C -No Glaucoma Yes C' No Lung Disease Yes.' No Thyroid Disease G Yes No chemotherapy. Yes C No Hay Fever Yes : No Mitral Valve Prolapse Yes ' No Tonsillitis C) Yes No chest Pains Yes.. No Heart Attack/Failure Yes C' No Osteoporosis Yes No Tuberculosis ''} Yes ': No Cold Sores/Fever Blisters C) Yes -No Heart I^urmur Yes, No Pain In }wi Joints Yes. No Tumors or Grovrths '",) Yes v.;. No Congenital Heart Disorder O Yes (: No Heart Pacemaker Yes NO Parathyroid Disease Yes No Ulcers 3 Yes No Convulsions Yes ' No Heart Trouble/Disease Yes No Psychiatric Care Yes No Venereal Disease Have you ever had any serious Illness not listed i,^ Yes \ No If ves Comments: Yellovj Jaundice Yes O No O Yes O No To 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 patients) health. It is my responsibility to Inform the dental office of any changes In medical status. Signature of Patient, Parent or Guardian: :

3 2100 Aloma Ave., Suite 200 Winter Parl<, Fl Dental Financial Policy and Agreement Thank you for choosing us for your dental needs. We are committed to providing you with excellent care. Our convenient financial arrangements are based on an open and honest discussion of recommended treatment options. PAYMENT Payment in full is due at the time of service unless prior financial arrangements are made. We offer several payment options: Cash, Checks, Visa, MasterCard, Discover and American Express Care Credit for patients interested in making payments over a 6 month period INSURANCE Our office is committed to helping our patients maximize their benefits. Because insurance policies vary greatly, we can estimate your coveracie in good faith, but cannot guarantee it. As a service to our patients, we will be happy to manage all claim submission and follow up on your behalf. If there is a difference in dollar amount due, a statement will be sent to you and is due upon receipt. MISSED/CANCELLED APPOINTMENTS Once an appointment has been made, that time is reserved specifically for you- we do not double book. We reserve the right to charge a fee ($50) for all appointments cancelled or missed without a full 24 hours notice. Appointments made for Mondays need to be cancelled by 3pm on the previous Thursday. SERVICE CHARGES There is a billing fee and a monthly interest fee of 1% on all accounts 60 days past due. COLLECTION FEES Fees incurred to collect payment will be billed to and payable by the patient's account holder. FINANCIAL CONSENT The patient (account holder) agrees to be fully responsible for total payment of treatment performed in this office. RESPONSIBLE PARTY The responsible party (the insurance policy holder) is responsible for the financial agreement listed above for all patients under said insurance policy I understand and agree to this Financial Policy and Agreement Signature of Patient/Responsible Party Print Name of Patient/Responsible Party

4 2100 Aloma Avenue Suite 200 Winter Park, FL ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the Notice of Privacy Practices. This notice describes how my health information may be used or disclosed. I understand that I should read it carefully. In addition, I am aware that the notice may be changed at anytime. I may obtain a revised copy of the notice by requesting one at this office. Signature Printed or typed name As the representative of the above individual, I acknowledge receipt of the notice on his/her behalf. Signature Relationship Printed or typed name

5 Dental Clinic Street Address, Phone ( } Why did you of Last Appt. DENTAL HISTORY of Birth. Dentist's Name _C!ty_ State.Zip of Last X-Rays_ leave your previous dentist?_ Check (t^) it you have or have had problems with any of the following: Bad breath No Chew on one side of mouth Yes No Bleeding gums.t DYes No Tobacco use Yes No Gums swollen or tender LJYes No Chewing on foreign objects Yes No Sores, blisters, growths on lips or mouth Yes No Fingernail biting. DYes L; NO Burning sensation on tongue Yes No Thumb sucking Yes No Biting cheeks or lips Yes No Tongue thrusting Yes No Dry mouth Yes No Pain on brushing teeth DYes No Mouth breathing Yes No Loose or broken teeth LJYes No Chewing Yes No Loose Of broken fillings - HYes No Swallowing Yes No Food collection between the teeth Yes No Talking Yes No Sensitivity to cold Yes No Prominent gag reflex Yes No Sensitivity to hot Yfes No Snoring Yes No Sensitivity to sweets Yes [71 No Periodontal treatment Yes No Sensitivity when biting Yes No Pyorrhea or trench mouth Yes No Stained teeth».-cyes No OrthocJontic treatment Yes No Grinding or clenching leeth Yes No Wisdom teeth extracted Yes No Clicking or popping jaw Yes No Bite problems Vfes No Jaw pain or fatigue. OYBS No Missing teeth Yes No Opening or closing jaw Yes NO Shifting position of teeth Yes '~ No Pain around ear C Yes No How often do you brush? How often do you have your teeth cleaned?,. How often do you change toothbrushes? Hovv often do vou floss? PATIENT GOALS What is your goal for dental treatment today?. Ace you in discomfort today? [jyes No Are you pleased with the appearance of your teeth? C Yes No If no. please explain Do you like your smile? Ll Yes LJNo If no, please explain Does dental treatment make you nervous? C. Yes No If yes, please explain Have you been pleased with your previous dental care? i_j Yes No ;iave you ever had a bad experience in a dental office? If so, explain_ How can we help improve your teeth and smile?. Vert OISFWOS tioom CQOOS ModioM Arts!>raM S i -a00-.'»a.2170

PATIENT REGISTRATION

PATIENT REGISTRATION Name: Date: First MI Last Preferred Name: RESPONSIBLE PARTY: (if someone other than the patient) First Name: Last Name: Middle Initial: Address: City: State: Zip: Home #: Work #: Ext: