Birth Date. Social Security #

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1 Todays Address PERSOAL IFORMATIO First ame Last ame Middle ame Birth Age I Prefer To Be Called Gender Male Female Marital Status Select an option Social Security # Home Phone# Cell# Work# Driver Lic. # ES Ballard Family Dentistry uses as a form of appointment confirmation. May we do so? Where and when are the best times to reach you? Whom may we thank for referring you? Employer: EMPLOER IFORMATIO How Long There? /PO Box ame Employer PERSO RESPOSIBLE FOR ACCOUT IF OTHER THA OURSELF Relation Home Phone# Work Phone# Driving Lic.# Billing Address Emergency Contact First ame Last ame Phone umber SPOUSE IFORMATIO His/Her ame Employer Birth Work Phone# Social Security# Driver Lic. # ISURACE IFORMATIO Medical Coverage? ES Dental Coverage? ES Orthodontic Coverage? ES Insurance Co. ame: Phone#: Group# (Plan, Local, or Policy#): ISURACE CO. ADDRESS lnsured's ame lnsured's Social Security# lnsured's Birthdate Relation Insured's Employer: EMPLOERS ADDRESS

2 MEDICAL HISTOR Do you have a personal physician? ES Physician's ame Physician's Address our current physical health is GOOD Are you currently under the care of a physician? FAIR POOR ES ES Please explain: Do you smoke or use tobacco in any other form? How much do you smoke or use per day? ARE OU ALLERGIC TO A OF THE FOLLOWIG? Aspirin Barbiturates Codeine Erythromycin ES Jewelry / Metals ES Latex Dental Anesthetics ES ES ES ES ES ES Please list additional drugs / materials that cause allergic reactions: Penicillin FOR WOME: Are you taking birth control pills? our current physical health is Week# Unsure Are you nursing? Sedatives ES Sulfa Drugs ES Tetracycline Other ES ES ES ES ES HAVE OU EVER OR ARE OU TAKIG A OF THE FOLLOWIG? Acetaminophen Alendronate (fosamax) Antibiotics Antihistamines Aspirin Bisphosphonate Steroids / Cortisone Tiludronate (Skelid) Blood Thinners Blood Pressure Medication Cold Remedies Digitalis/ Heart Medication Etidroname Disodium(Vidronel) Insulin / Diabetes Drugs Tiludronate (Skelid) (Zometa) Tranquilizers lbandronate ( Boniva) itroglycerin Pamidronate (Aredia) Recreational Drugs Tetracycline Risedronate (Actonel) Tiludronate (Skelid) Drug Abuse Emphysema Epilepsy Fainting Spells Glaucoma Hay Fever Headaches Heart Attack Are you taking any prescription/ over-the-counter-drugs not listed above? e list additional drugs / materials that cause allergic reactions: ES Please list any medications you are currently taking: DO OU OR HAVE OU EXPERIECED THE FOLLOWIG? Abnormal Bleeding Alcohol Abuse Anemia Arthritis Asthma Blood Transfusion Cancer Chemotherapy Chicken Pox Colitis Congenital Heart Defect Artificial Bones/ Joints Diabetes High Blood Pressure STD/ Venereal Disease Hospitalized for Any Reason

3 Heart Murmur Heart Surgery Hemophilia Hepatitis Herpes HIV+/ AIDS Kidney Problems Liver Disease Lupus Mitral valve Prolapse Pacemaker Persistent Cough Psychiatric Problems Radiation Treatment Rheumatic Fever Scarlet Fever Seizures STD/ Venereal Disease Sickle Cell Disease Sinus Problems Steroid Therapy Stroke Thyroid Problems Tonsillitis Tuberculosis (TB) Ulcers Shingles If other (please list): DETAL HISTOR Why have you come to the dentist today? Are you currently in pain? ES Please rate your pain on a scale of 1-10 with 1 being little pain and 10 being unbearable pain. Previous/ Present Dentist: /PO Box Phone umber When was your last: cleaning? oral cancer test? Why did you leave your previous dentist? What did you like most & least about any dentist you have seen? Do you require antibiotics before dental treatment Po you now or have you ever experienced pain or discomfort in your jaw joint (TMJ / TMD)? Do you have headaches, ear aches, neck or jaw pain? Do you floss daily? ES Do you use anything in addition to floss? Brush daily? ES ES ES ES ES If yes, what? Do you or have you ever suffered from extreme dry mouth? ES Do you still have wisdom teeth? ES Whiten my teeth? Make my teeth straighter? ES ES Close spaces between teeth? ES Replace metal fillings with tooth colored ones? ES Repair chipped teeth? ES Replace missing tooth? Replace old crowns that don't match? ES ES Have a smile make over? ES Are you happy with the way your smile looks? Please rate your smile on a scale of 1-10 with 10 being the best IF I COULD CHAGE M SMILE, I WOULD

4 O A SCALE OF 1-10, WITH 10 BEIG THE HIGHEST RATIG: How important is dental health to you? Lowest Highest 9 10 Highest How would you rate your current dental health? Lowest Ballard Family Dentistry Courtesy Billing Our office requires at least 72 hour notice prior to an appointment Cancellation or Change. As a courtesy to you, we will verify your insurance benefits, file all of your dental claims, inform you when your insurance company has neglected to pay the estimated amount and we will file an appeal on your behalf when necessary. ou will be responsible for paying your co-payments and deductibles at the time of service, paying any remaining balance after insurance payments are received, providing us with the most current insurance information, and being aware of your dental benefits and coverage. I have read and understand the conditions of the Courtesy Billing Options above. I certify that I am covered by Insurance Co. and I assign directly to Ballard Family Dentistry all insurance benefits. I understand that I am responsible for payment of services rendered, and also responsible for paying any co-payments and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. Print ame Signature HIPPA Patient ame of Birth Social Security# Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activates, and healthcare operations. otice of Privacy Practices: ou have the right to read our otice of Privacy Practices before you decide whether to sign this Consent. Our otice provides a description of our treatment, payment activities, and healthcare operations, of the use and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our otice accompanies this consent for your review. We encourage you to read it carefully and completely before signi ng this Consent. We will be happy to provide you a copy for your records if you wish. We reserve the right to change our privacy practices as described in our otice of Privacy Practices. If we change our privacy practices, we will issue a revised otice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. Right to Revoke: ou have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the office manager. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

5 Consent: Parent/Guardian I, have had full opportunity to read and consider the contents of this Consent Form and otice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. Signature If this Consent is signed by a personal representative on behalf of the patient complete the following: Relationship to Patient: OU ARE ETITLED TO A COP OF THIS COSET AFTER OU SIG IT. Standard of Care at Ballard Family Dentistry Patient ame of Birth Fluoride Treatment: I understand that I will receive fluoride treatment at every cleaning appointment unless otherwise requested differently by me. I also understand that if I choose not to have fluoride for myself or child that it is my responsibility to inform the dental hygienist before the cleaning begins. X-Rays: I understand that if I am transferring from another dental office, it is my responsibility to inform Ballard Family Dentistry that xrays were taken at another dental office. X-rays are standard of care at Ballard Family Dentistry and will be taken at least a minimum of 1 set every 12 months. Missed Appointments: I understand that when I reserve an appointment with Ballard Family Dentistry, I am committing myself to the specified day and time. I understand that Ballard Family Dentistry does not charge a cancellation fee for emergency situations. I also understand that if I abuse the cancellation policy, which requires a 24 hour notice, I could incur a fee of $20.00 if I miss my appointment. Payment Policy & Insurance: I understand that my payment is due at the time services are rendered. I also acknowledge and agree that payment in full is required if my insurance cannot be verified prior to my appointment. I understand that Ballard Family Dentistry files my primary insurance. I acknowledge and agree that it is ultimately my responsibility as the patient/parent to know what my insurance plan covers and any unpaid balance not covered by insurance is my responsibility. I understand that as the parent, I am responsible for my child while under the care of Ballard Family Dentistry. I understand that should I allow someone other than myself to bring my child to his/her appointment, that any documents signed by that person or verbal acknowledgments given by that person is ultimately my responsibility and will fall back upon me. Patient/Guardian/Parent Signature