Name: Last First Middle. Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Street City State Zip

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1 PATIENT INFORMATION Name: Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / Social Security Number: - - Driver s License #: RESPONSIBLE PARTY INFORMATION (If Patient is a Dependent) Name: Relationship to Patient: Primary Policy Holder s Date of Birth: / / Address: Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / DENTAL INSURANCE INFORMATION (Please Provide a Copy of Your Card) Social Security Number: - - Driver s License #: Name of Primary Holder : Primary Policy Holder s SS / ID Number: - - Primary Policy Holder s Employer: Insurance Company Name: Group Number: Insurance Company Phone: ( ) Insurance Company Address: EMERGENCY CONTACT INFORMATION Emergency Contact Name: Emergency Contact Phone: ( ) Emergency Contact Address: FOR ALL PATIENTS 4001 Geist Rd. Suite B Fairbanks, AK I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the dental care of the patient above, and further authorize and consent that the doctor chooses and employs such assistance as he deems fit. I also understand that prior to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or his staff. I agree to pay for all services rendered by this office. SIGNATURE OF RESPONSIBLE PARTY RELATIONSHIP TO PATIENT (IF APPLICABLE) DATE

2 MEDICAL HISTORY Name: Date of Birth: / / 1. Have you been under the care of a medical doctor during the past two years?... Yes No If yes, for what reason? 2. Are you having dental problems at this time?... Yes No 3. Do your gums bleed at any time?... Yes No 4. Are you allergic to (i.e., itching, rash, swelling on hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any drugs or medications?... Yes No If yes, please list: 5. Have you ever had excessive bleeding requiring special treatment?... Yes No 6. Check any of the following which you have had or have at present: Ulcers Heart Disease or Attack Shortness of Breath Tuberculosis (TB) Hepatitis B (Serum) Asthma Liver Disease Rheumatic Fever Diabetes Scarlet Fever Thyroid Disease Artificial Heart Valve Chemotherapy (Cancer, Leukemia) Heart Pacemaker Arthritis Heart Surgery cortisone Medication Artificial Joint Glaucoma Stroke Pain in Jaw Joints Kidney Trouble HIV Positive (AIDS) Hepatitis A (Infectious) High Blood Pressure Heart Murmur / Mitral Valve Bruise Easily Drug Addiction Hemophilia Cold Sores or Fever Blisters Epilepsy or Seizures Nervousness Psychiatric Treatment 7. Do you have any disease, condition, or problem not listed?... Yes No If yes, please list: 8. List all medication you are taking at this time. 9. Are you a smoker?... Yes No 10. Do you use or have you ever used recreational drugs?... Yes No 11. Do you ever wake up from sleep short of breath? Do you snore?... Yes No 12. Do you clench or grind your teeth?... Yes No 13. Has your medication doctor ever said you have cancer or a tumor?... Yes No 14. Woman: Are you pregnant?... Yes No If yes, what month are you due? UPDATES (date & Initial):

3 INGERSOLL FAMILY DENTISTRY Acknowledgement of Receipt of Notice of Privacy Practices I have received a copy of this office s Notice of Privacy Practices dated November 1, 2017 *You may refuse to sign this acknowledgement* Printed Name: Signature: Date: OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, as required by law, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (specify):

4 4001 Geist Rd. Suite B Fairbanks, AK FINANCIAL POLICY Thank you for choosing us as your dental health care provider. We believe that all patients deserve the very best dental care we can provide. We also believe that everyone benefits when specific financial arrangements are agreed upon. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require that you read and sign prior to any treatment. Full payment is due at time of service, patients who have dental insurance will be responsible to pay the amount of their estimated co-payment and deductible. We accept cash, checks, all major credit cards and debit cards. We also offer Care Credit which is an extended payment plan with prior credit approval. INSURANCE Ingersoll Family Dentistry proudly accepts most dental insurance plans. We file all dental insurance claims as a patient courtesy. In the event of a treatment plan, we create a reasonable estimate of patient co-payments and insurance contributions. This estimate is based on contracted insurance rates, the general breakdown of benefits obtained through the insurance verification process of our knowledge of common insurance exclusions. This estimate is not a guarantee of insurance payment. All benefit determinations are at the discretion of the insurance company and are not determined until after a claim is submitted. We provide treatment estimates as a courtesy in order to minimize the total out-of-pocket cost due by patient. All estimated patient co-payments are due on or before time of service. Patient is responsible for any remaining account balance resulting from insurance nonpayment or underpayment. A statement will be mailed to you regarding this balance. Payment is due immediately upon receipt. FULL PAY CASH DISCOUNT We offer a 5% courtesy discount on all treatment paid in full at time of service if paid with cash. CANCELLATION POLICY Ingersoll Family Dentistry makes an effort to see patients on time in order to give patients the care they deserve. Therefore, we ask that you please give 48 hours notice if you are unable to keep your scheduled appointment. We reserve the right to charge a cancellation fee of $75.00 in the event of missed appointments lacking proper notice. We will make exceptions in the event of reasonable emergencies. COLLECTIONS Any account that has not received payment in 90 days will be handed over to a collection agency that will pursue the responsible party for reimbursement. This will negatively impact your credit history and limit the treatment you can receive at our office. PATIENT ACKNOWLEDGMENT AND AUTHORIZATION I understand and agree to the Ingersoll Family Dental Financial Policy stated above. Please let us know it you have any questions or concerns. We look forward to providing the highest quality dental care in a relaxing and caring environment. Printed Name: Signature: Date:

5 / TEXT APPOINTMENT REMINDERS I, would like to receive text and/or appointment reminders. Printed Address: Cell Phone Number: ( ) Cellular Provider: GCI AT&T Verizon Sprint T-Mobile Other: IMPORTANT NOTE: Please do not or text any changes, questions, or cancellations to your e-message reminder. If you need to discuss and/or adjust your appointment, please call our office directly. I agree to receive e-message correspondence from Ingersoll Family Dentistry. Signature: Date: