PATIENT INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:

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1 PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed address: Occupation: Work Phone: Whom may we thank for referring you to our office: SPOUSE INFORMATION (if applicable) Full name: Preferred name: Home phone (if diff.): Cell phone: Work phone: PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT (if different) Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Employer: Work phone: PRIMARY INSURANCE INFORMATION Insured s name: Date of birth: Social Security #: Patient s relationship to insured: self spouse child other Insurance company: Insurance phone: Insurance address:_ Employer s name: Group #: Employee s ID #: SECONDARY INSURANCE INFORMATION Insured s name: Date of birth: Social Security #: Patient s relationship to insured: self spouse child other Insurance company: Insurance phone: Insurance address:_ Employer s name: Group #: Employee s ID #: AUTHORIZATIONS AND RELEASES I consent to examination by Dr. Baldree and authorize him to perform diagnostic procedures and treatments as may be necessary for proper dental care. I authorize release of any information pertaining to my health care, advice, and treatments provided to third party payers or to other health care practitioners. I authorize my insurance company to pay directly to Dr. Baldree all benefits otherwise payable to me. I understand that my dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I agree to be fully responsible for the total payment for procedures performed in this office, as well as for any necessary collection and attorney fees. I give permission for the use of photographs and records made in the process of examination and treatment to be used for the purposes of research, education, or publication in professional journals. Signature: Relationship to Patient: Date: REGISTRATION

2 Patient Name: DOB: Please rate the overall condition of your health: excellent good fair poor Physician Specialty Date of Last Visit Reason for Visit Have you been hospitalized or had surgery or any serious illness in the past 5 years? If so, please explain: Have you ever had any reactions to local or general anesthesia? If so, please explain: Have you ever experienced excessive bleeding following dental or surgical procedures? If so, please explain: Has a physician ever told you to take special medication before dental work? If so, please explain: Are you allergic to any medications? If so, please list: Are you allergic to latex? Any other dental materials? If so, please list: Are you currently taking any medications, pills, or drugs? If so, please list: Have you ever taken medication to strengthen your bone, as for osteoporosis or cancer treatments? If so, please explain: Do you use any tobacco products? If so, what type? How much? (Women) Are you now or are you currently trying to get pregnant? If so, what is your due date? Do you currently have or have you ever experienced any of the following conditions or diseases? damaged heart valves, heart murmur, rheumatic fever, respiratory problems, tuberculosis, bronchitis, emphysema scarlet fever arthritis, painful swollen joints, rheumatism prosthetic heart valve, prosthetic joint bone, muscle, or skin diseases cardiovascular disease, high blood pressure, stomach ulcers, digestive system disorders or diseases arteriosclerosis, stroke, heart attack, chest pain, kidney trouble shortness of breath, congestive heart failure sexually transmitted diseases blood disorders, anemia, hemophilia, sickle cell disease, epilepsy, seizure disorders, neurological diseases prolonged healing cancer, cancer treatments, chemotherapy, radiation allergies, asthma, hayfever, sinus trouble, anaphalaxis treatments diabetes immune system disorders, prolonged steroid treatments liver disease, hepatitis, jaundice drug or alcohol abuse or addiction AIDS, ARC, HIV psychological or psychiatric treatments thyroid problems, endocrine disorders injury to head, neck, or back Please explain any positive responses: Do you have any disease, condition, or problem not listed above that we should be aware of? If so, please explain: In case of emergency, name of nearest relative not living with you: Phone: Signature: Date: Relationship to Patient: Reviewed by: Date: MEDICAL HISTORY

3 Patient Name: DOB: Date: What is your PRIMARY CONCERN or reason for seeking treatment in this office? Previous Dentists Date of Last Visit Reason for Visit When was your last cleaning? When was your last full mouth dental x-ray taken? How often do you go to the dentist? How often do you brush your teeth? How often do you floss? Do your gums bleed while brushing or flossing? Do your gums ever feel tender or swollen? Have you ever had gum treatment or surgery? If so, what kind? When? Have you ever had orthodontic treatment (braces)? If so, when? Do you clench or grind your teeth? Does your jaw click or pop? Have you experienced pain or soreness in the muscles of your face or around your ear? Can you chew on both sides of your mouth? Comfortably? Do you have frequent headaches? Earaches? Neck aches? Do you have difficulty in opening or closing your mouth? Have you ever had an injury to your teeth, mouth or jaws? Have you ever had any type of mouth tumor, growth, or cancer? Do you get frequent fever blisters, canker sores, or mouth ulcers? Are you teeth sensitive to: hot? cold? sweets? pressure/chewing? Do you tend to lose or break fillings? Do you usually have many cavities? Do you have noticeable wear on your teeth? Food traps? Do you have missing teeth? How did you lose them? (check as many as apply) decayed/rotten gum disease/bone loss infected/abscessed congenitally missing/never formed other Have they been replaced? If so, how? (check as many as apply) permanent bridge (date placed ) removable partial (date placed ) full denture (date placed ) dental implants (date placed ) Are you comfortable with the replacement? Please describe. How do you feel about the appearance of your smile? Have you ever had any cosmetic dentistry done to improve your appearance? If so, are you pleased with the results? Please comment: How do you feel about your teeth in general? Have you ever had any problems of complications with previous dental treatments? Please explain: Have you ever had an unpleasant dental experience or is there anything about dentistry that you strongly dislike? Please add anything you feel is important. DENTAL HISTORY

4 G. Mitchell Baldree, DDS Member, American College of Prosthodontists 200 W. Main Street Chattanooga TN FINANCIAL POLICIES Our office strives to provide the highest quality restorative care possible. We are sensitive to the consideration you must give to the cost of your dental care. We welcome frank discussion of services and fees prior to treatment in order to avoid misunderstandings. Our customary arrangement is full payment for basic dental care (cleanings, fillings, etc.) on the day provided. For prosthetic care (crowns, bridges, implants) we request ½ at the time treatment is begun. For partials and dentures we request payment of at least one-third of the total cost at the time treatment is started. The TOTAL FEE MUST BE PAID BY THE TIME THE WORK IS DELIVERED. A 4% bookkeeping courtesy is given on all cases over $1000 when paid in advance by cash or check. Payment agreements with financial coordinator must be made prior to treatment. Balances remaining on accounts after 90 days, or after the completion of treatment, will be subject to a 1.5% monthly finance charge. INSURANCE As a courtesy to you, we are happy to file your insurance claims and will accept assignment of benefits as co-payment for dental services. For prosthetic care, we will apply insurance co-payment towards the balance if benefits have been predetermined. Because of the time required for filing and reimbursement, however, we are unable to apply insurance co-payments towards the initial payment for prosthetic services. Please remember that your insurance policy is a contract between you and your insurance company, and it rarely covers all costs. We will do all we can to assure that you obtain maximum benefits from your policy. However, you are ultimately responsible for your entire account balance, including any deductible amounts and any balances not paid by your insurance company after 45 days. Rest assured that you will be promptly reimbursed should your account be overpaid due to an underestimated or delayed insurance payment. For medical claims you will be responsible for the full balance after insurance as we do not accept assignment. I assume full responsibility for my account balance as well as full responsibility for outstanding insurance claims after 45 days without payment to this office. Any necessary collection or attorney fees dealing with my account are to be paid by me along with interest charges and late fees. Signed: patient/guarantor date

5 G. Mitchell Baldree, D.D.S. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received a copy of this office s Notice of Privacy Practices. Patient s Name (Please Print) Patient s Signature (over 18 years of age) Date OR (if under 18 years of age) Signature of Authorized Patient Representative Date Relationship to Patient For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Parent not present with patient; requested form to be returned with parent s signature. Individual refused to sign. Communications barriers prohibited obtaining the acknowledgement. An emergency situation prevented us from obtaining acknowledgement. Other (Please Specify): Employee Signature Date: HIPPA Form Nov 2006