Welcome Patient

Soc.Sec.# Last Name First Name Initial

Preferred/Nickname:_______________________

Home Address: P0 BOX:

City: State: Zip_____________ Home Phone:

Work Phone: _________________ Ext. Cellular Phone:

Birth Date: Drivers Lic: Sex: 0 Male

0 Female

Marital Status: 0 Married 0 Single 0 Divorced 0 Separated 0 Widowed

Employer: Insurance Company:

E-Mail address:

Whom can we thank for referring you?___________________________

Emergency Contact name/#:

Primary Insurance/Responsible Party

Subscribers Name: Last Name First Name Initial

Relationship to Patient: Soc.Sec.#_________________________________

Physical Address: P0 BOX:

City: State:Zip____________ Home Phone:__________________________

Work Phone: Ext. Cellular Phone:

Birth Date: Drivers Lic: Sex: 0 Male 0 Female

Marital Status: 0 Married 0 Single 0 Divorced 0 Separated 0 Widowed

Employer: Insurance Company:

Secondary Insurance/Responsible Party

Subscriber Name: Last Name First Name Initial

Relationship to Patient: Soc.Sec.#__________

Physical Address: P0 BOX: -

City: State: Zip Home Phone

Work Phone: Ext. Cellular Phone:

Birth Date: Drivers Lic: Sex: 0 Male

0 Female

Marital Status: OMarried 0 Single 0 Divorced 0 Separated 0 Widowed

Employer: Insurance Company:

Acceptable Means of Communication

It is acceptable to discuss health and or billing information by the following means: • You may leave a information on my home voice mail: fl (yes), (no) • You may leave information on my cell phone voice mail D(yes, (no) • You may send me an email 0 (yes), (no) 0

Special Instructions:

It is acceptable to send a text message for the following: o Appointment Reminders O Continuing Care

It is acceptable to send email messages for the following: o Birthday wishes O Thank You

Continuing Care [] Appointment Reminders o Coupons, Special Announcements

Please List authorized persons with whom we may discuss your Protected Health Information:

Name: Phone Number: Relationship: Info Authorized, i.e. (pick up xrays)________________

Name: Phone Number: Relationship: Info Authorized, i.e. (pick up xrays)_______________

Name: Phone Number: Relationship: Info Authorized, i.e. (pick up xrays)________________

Name: Phone Number: Relationship: Info Authorized, i.e. (pick up xrays)________________

Name: Phone Number: Relationship: Info Authorized, i.e. (pick up xrays)________________

I authorize Quality Dental to take radiographs, study models, photos, and other diagnostic aids or material as needed to make a thorough diagnosis. I authorize that such Diagnostic Material may be released to third-party payors and/or other health professionals.

I authorize Quality Dental to release to staff, hospitals, health care service plans, insurance companies, self-insurers or their representatives, any and all information records, and other Diagnostic Material about my medical history, services rendered, or recommended treatment.

I authorize Quality Dental to submit claims for payment for services rendered or pre authorizations necessary to my insurance company, on my behalf and in my name listed as "signature on file" and assign to Quality Dental the insurance benefits providing assignment is accepted. I am responsible for payment regardless of coverage provided.

I hereby authorize, as indicated by my signature below; to use and to disclose my protected health information for any clinical, financial, and insurance purpose, as indicated above.

Patient/Guardian Signature: Date:

Print Name:

TIME 12:12 PM Ladysmith Dental Center, Inc DATE 1012112015

MEDICAL HISTORY

PATIENT NAME

Birth Date

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 taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

following questions.

Are you under a physician's care now? Q Yes 0 No

Have you ever been hospitalized or had a major operation? Q Yes 0 No

Have you ever had a serious head or neck injury? 0 Yes 0 No

Are you taking any medications, pills, or drugs? Q Yes 0 No

Do you take, or have you taken, Phen-Fen or Redux? Q Yes Q No

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes 0 No

If yes, please explain:

If yes, please explain:

If yes, please explain:

If yes, please explain:

Are you on a special diet? 0 Yes Q No

Do you use tobacco? Q Yes Q No

Do you use controlled substances? Q Yes Q No

Women: Are you Pregnant/Trying to get pregnant? Q Yes Q No Taking oral contraceptives? Q Yes Q No Nursing? Q Yes 0 No

Are you allergic to any of the following?

Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Eli Latex D Sulfa drugs

Other If yes, please explain:

Do you have, or have you had, any of the following? .................

AIDSII-IIV Positive Q Yes Q No Cortisone Medicine 0 Yes Q No Hemophilia 0 Yes 0 No Radiation Treatments 0 Yes 0 No Alzheimer's Disease 0 Yes Q No Diabetes Q Yes 0 No Hepatitis A 0 Yes 0 No Recent Weight Loss Q Yes 0 No Anaphylaxis 0 Yes 0 No Drug Addiction Q Yes Q No Hepatitis B or C 0 Yes 0 No Renal Dialysis 0 Yes 0 No Anemia 0 Yes Q No Easily Winded Q Yes Q No Herpes 0 Yes 0 No Rheumatic Fever Q Yes Q No

Angina 0 Yes Q No Emphysema 0 Yes Q No High Blood Pressure 0 Yes Q No Rheumatism 0 Yes Q No Arthritis/Gout 0 Yes 0 No Epilepsy or Seizures 0 Yes 0 No High Cholesterol 0 Yes Q No Scarlet Fever 0 Yes Q No Artificial Heart Valve 0 Yes 0 No Excessive Bleeding 0 Yes 0 No Hives or Rash 0 Yes 0 No Shingles 0 Yes 0 No Artificial Joint 0 Yes 0 No Excessive Thirst 0 Yes 0 No Hypoglycemia 0 Yes 0 No Sickle Cell Disease 0 Yes 0 No Asthma 0 Yes 0 No Fainting Spells/DizzinessQ Yes 0 No Irregular Heartbeat 0 Yes 0 No Sinus Trouble 0 Yes Q No Blood Disease Q Yes 0 No Frequent Cough 0 Yes 0 No Kidney Problems 0 Yes 0 No Spina Bifida Q Yes 0 No Blood Transfusion 0 Yes 0 No Frequent Diarrhea 0 Yes 0 No Leukemia 0 Yes 0 No Stomach/Intestinal Disease 0 Yes 0 No

Breathing Problem 0 Yes 0 No Frequent Headaches 0 Yes 0 No Liver Disease 0 Yes 0 No Stroke 0 Yes 0 No

Bruise Easily Q Yes 0 No Genital Herpes 0 Yes 0 No Low Blood Pressure 0 Yes 0 No Swelling of Limbs 0 Yes 0 No

Cancer 0 Yes Q No Glaucoma 0 Yes 0 No Lung Disease 0 Yes 0 No Thyroid Disease 0 Yes 0 No

Chemotherapy 0 Yes 0 No Hay Fever 0 Yes 0 No Mitral Valve Prolapse 0 Yes 0 No Tonsillitis Q Yes Q No

Chest Pains Q Yes 0 No Heart Attack/Failure 0 Yes 0 No Osteoporosis 0 Yes Q No Tuberculosis Tumors or Growths

Q Yes 0 No 0 Yes j No

Cold Sores/Fever Blisters 0 Yes 0 No Heart Murmur 0 Yes Q No Pain in Jaw Joints 0 Yes 0 No

Congenital Heart DisorderO Yes 0 No Heart Pacemaker 0 Yes 0 No Parathyroid Disease 0 Yes 0 No Venereal Disease 0 Y:: 0 No

Convulsions Q Yes Q No Heart Trouble/Disease Q Yes 0 No Psychiatric Care 0 Yes Q No Yellow Jaundice 0 Yes 0 No

Have you ever had any serious illness not listed above? 0 Yes Q No

Comments:

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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

Financial & Insurance

Your treatment plan will include a breakdown of all applicable fees, and we will inform you of all costs

before treatment is administered. Charges are payable at the time of treatment.

We offer a variety our payment options to accommodate your financial needs, including:

. Cash and Checks

Visa, MasterCard, Discover and American Express

• Care Credit

INSURANCE REIMBURSEMENT ON FILLINGS

This office uses only resin (tooth colored) fillings and not amalgam (metal) fillings. Some insurance

companies will reimburse for amalgam filling price if a resin filling was done. We will bill you for the

difference of the resin filling after the insurance payment has been received. If you have any

questions about this please ask one of our staff or the doctor.

Insurance

We are a preferred provider with most PPO dental insurance plans and The Virginia Smiles for

Children/Medicaid plan. We will fully attempt to help you receive full insurance benefits; however, you

are personally responsible for your account, and we encourage you to contact us if your policy has not

paid within 30 days.

PLEASE REMEMBER THAT YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR

INSURANCE COMPANY. IT IS ULTIMATELY THE PATIENT'S RESPONDIBILITY TO KNOW AND

UNDERSTAND THEIR DENTAL BENEFITS. WE ARE NOT A PARTY TO THIS CONTRACT. YOU ARE

ULTIMATELY RESPONDSIBLE FOR YOUR BILL, AND YOU WILL BE REQUIRED TO PAY FOR ANY

SERVICES NOT PAID BY YOUR INSURANCE.

RETURNED CHECKS AND MISSED APPOINTMENTS

* There will be a $35.00 handling fee applied to your balance for any checks returned by the bank.

**please remember that when an appointment is scheduled this time has been specifically reserved for

you. There is no charge to reschedule an appointment provided that 48 hours notice is given. A broken

appointment fee of $20.00 per half hour of reserved time may be incurred if proper notice is not given.

Daily appointments 3 pm and later & Saturday Appointments: These appointments are in high demand.

Therefore, we require 48 hours notice to reschedule or cancel an appointment. If for some reason you

are unable to keep your appointment, you will be charged a $20 broken appointment fee per half hour

of scheduled time, and you will not be permitted to schedule evening or Saturday appointments again.

DIVORCE

In case of divorce or separation, the party responsible for the account prior to the divorce or

separation remains responsible for the account. After a divorce or separation, the parent authorizing

treatment for a child will be the parent responsible for the subsequent charges. If the divorce decree

requires the other parent to pay all or part of treatment costs, it is the authorizing parent's

responsibility to collect from the other parent.

FINANCIAL/OFFICE CONSENT

I agree to be fully responsible for my account. I will pay for services as they are rendered. I have read

and understand that by signing this form I am agreeing to the terms and agreements listed.

Patient's/Guardian's Signature Date

NOTICE OF PRIVACY PRACTICES

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 activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide

whether to sign this consent. Our notice provides a description of our treatment, payment activities,

healthcare operations, the uses and disclosures we make of your protected health information, and of

other important matters about your protected health information. You may obtain a copy of the Notice

of Privacy Practices at any time by contacted our office. We reserve the right to change our privacy

practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will

issue a revised Notice of Privacy Practices, containing all changes. Those changes may apply to any of

your protected health information that we maintain.

I have had the full opportunity to read and consider the contents of this consent form and your Notice

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

healthcare operations.

Patient's/Guardian's Signature

Date

Guardians name and relation to patient:

Revocation of Consent: I revoke my consent for your use and disclosure of my protected health

information for treatment, payment activities, and healthcare operations. I understand that revocation

of my consent will not affect any action taken in reliance on my consent before receipt of this written

Notice of Revocation. I also understand that you may decline to treat me after I have revoked my

consent.

Patient's/Guardian's Signature Date