Work Phone#:( )_. Do you have children? QYes [UNo How Many? CellPhone#:( Payment Method: Cash Check

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1 800 South Washington Afton, WY Petersen Parkway Suite #3 Thayne.WY Today's Date:_ / / Patient Name: What you Prefer to Be Called:_ Birth date: / / Age:_ Mailing Address: Home Phone#:(_ SS#: Male DFemale Person Ultimately Responsible for Account Name: Relation: BillingAddress: Work Phone#:(_ CellPhone#:( Address:_ Referred By: Employer: Employer's Address:_ How Long?_ SS#: DOB: / / Work Phone#:( )_ Payment Method: Cash Check Credit Card (please put card info below) Card # Occupation: Status: QMinor Single Married Divorced ^Separated widowed Spouse's Name: Do you have children? QYes [UNo How Many? Do You Have Dental Insurance?D/es \Z\Uo (If Yes Please provide front office personnel with card so they can photocopy it.) DO NOT WRITE BELOW THIS LINE! Office Use Only I exp 3 digit code from back Care Credit (Please put card info below) Card# PLEASE INITIAL Ihereby authorize assignment of my insurance rights and benefits directlyto the provider for services rendered. I fully understand that Iam solely responsible for any balance not paid by my insurance company. Ihereby authorize that any unpaid balance that my insurance benefits did not pay to be charged to the credit card, or Care Credit # listed above. Whom should we contact?_ Relation Phone ( )_ Cell ( ). Who is your Medical Doctor?_ Medical Doctor's Phone #:( )_

2 Reason for today's visit: I lexam I [Emergency I [Consultation Are You inpain? QNo Yes How Long? Please indicate 0 any of the following problems: Discomfort, clicking or popping in jaw. Lost/Broken Filling(s) Stained teeth Red, swollen or bleeding gums. TeethGrinding Locking Jaw Sensitive tooth,teeth orgums. Ringing inears Bad Breath Blisters/Sores in or around the mouth. Broken/Chipped tooth/teeth Other: Do you requirepre-medication?q Yes No Idon't know PreviousDentist: Last Dental Exam: J /_ Last Dental Xray: J /_ Times a day you brush?_ Times a week you floss?_ Phone ( ) Whattype of tooth brushbristles do youuse? Soft Medium Hard How would you rate your smile? (worst) i (best) D^cgxolBc^c^D C=aB@G(o>LTW What medications are you taking? Nerve Pills Pain Killers (including aspirin) QMuscle relaxers Stimulants Blood Thinners ^Tranquilizer insulin QMeds for Osteoporosis. Others:_ Have you ever taken: Bisphosphonates (ex. Aredia/Fosamax) Yes No Phen-fen/Redux QYes ] No Doyou have or have you had any of the following diseases, medicalconditions or procedures? Y N Heart Attack/Stroke YN Thyroid Problems Y N Cancer/Tumors YN Cosmetic Surgery Y N Heart Surg./ Pacemaker Y N Kidney Problems YN Shingles YN Liver Problems ' YN Hepatitis A/B / C Y N Chemotherapy Y N Rheumatic Fever YN HIV+/AIDS/ARC YN Asthma Y N Mitral Valve Prolapse Y N Sinus Problems Y N Difficulty Breathing Y N Artifical Valves Y N Artificial Bones/Joints Y N Heart Disease Y N Emphysema Y N Leukemia Y N Heart Murmur Y N Respiratory Problems Y N Arthritis/Rheumatism Y N Psychiatric Problems Y N Seizures/Epilipsy Y N Scarlet Fever YN Jaw Problems TMJ/TMD YN Y N Anemia Y N Tuberculosis TB Back Problems Y N Congenital Heart Defect YN Venereal Disease Y N Alcohol/Drug Abuse YN Frequent Headaches Y N Bleeding Problems YN Nervousness Y N Stomach Problems YN Diabetes/Hypoglycemia Y N High/Low Blood Pressure YN Xray or Cobalt Treatment Please list any other surgeries or medical conditions you have had or ever have had: YN Chest Pains Y N Frequent Neck Pain Y N Glaucoma Areyou allergic to any of the following? Latex Penicillin/Amoxicillin Tetracycline Aspirin DentalAnesthetics Foods: ODthers: Do you use tobacco? Yes QNo (If Yes) How used? Please rate your general health from 1-10: How much? How Long?_ We Invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient. Office Use Only ; Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the Financial Coor dinator, If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses in curred in collecting your account. We file insurance as a courtesy to you and amounts quoted are only an estimate. Patient is responsible for entire balance regardless of insurance. j Updated Updated Updated _/ / / Initials Initials Initials! j j i I authorize the staff to perform any necessary services needed during Updated _J Initials diagnosis and treatment. I also authorize the provider to release any infor i Updated / Initials mation required to process insurance claims. Signature Date:

3 ^7 ^ M ^ V' rr ^ kfl fekfl^ NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosed and how you can get access tothis information. Please review carefully. The Privacy ofyour health information is important to us. OUR LEGAL DUTY We are required by applicable federal and state law tomaintain the privacy of your health information. We are also required to give you this notice about our privacy practices, andyour rights concerning your health information. Wemust follow the privacy practices that are described in this notice while it is ineffect. This notice takes effect on April 14, 2003 and will remain in effect until we replace it. We reserve the right tochange our privacy practices and terms ofthis notice at anytime, provided such changes arepermitted byapplicable law. We reserve the right make changesin our privacy practices and the terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in ourprivacy practices, we will change this notice and make the new notice available upon request. You may request a copy ofournotice at any time. For more information about ourprivacy practices, or for additional copies of this notice, please contact us using the information at the end of this notice. USES AND DISCLOSURE OF HEALTH INFORMATION We useand disclose health information about you for treatment, payment, and healthcare operations. For example: TREATMENT: We may useor disclose your health information to a physician or other healthcare provider providing treatment to you. PAYMENT: We may use and discloseyour health information to obtain payment for services we render to you. HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, certification, licensing, or credentialing activities. YOUR AUTHORIZATION: Inaddition to our use of your health information for treatment, payment, or healthcareoperations, your maygive us written authorization to use your health information or to disclose it to anyone for any purpose. Ifyou give us an authorization you may revoke it in writing at any time. Your revocation will not affect any use of disclosure permitted by your authorization while it was in effect. Unless yougiveus a written authorization, we cannot use or disclose your health information for any reason except those described in this notice. TO YOUR FAMILY ANDFRIENDS: We must disclose your health information to you, as described in the patient rights of this notice. We may disclose your health information to a family member, friendor other person to the extent necessary to help you with your healthcare or with payments for your healthcare, but only ifyou agree that we do so. PERSONS INVOLVED IN CARE: We may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, or your location, your general condition, or death. Ifyou are present, then priorto use or disclose or your health information, we will provide you with an opportunityto object such or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information

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