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V'l.'V'l/JLJ.JLThank you for selecting our dental healthcare team! We will strive to provide you with the best possible

dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If youhave any questions or need assistance, please ask us - we will be happy to help.

IDate

Birthdate

Social Security #

Name

E-Mail

D Male D Female

AddresiS

City

D Minor D Single D Married D Divorced D Widowed D Separated

State Zip

Employer Occupation

Referred by

2 Telephone

Home Phone

Work Phone

Cell Phone

Ext. #

Where do you prefer to receive calls? EH Home

When \s the best time to reach you? Time

In the event of an emergency, who should we contact?

Name Relationship

D Work

. Days _..

D Cell Phone

Work* Home #

+JResponsible Party

Who is responsible for the account?

Name

Relationship to patient

Birthdate

Social Security #

Address

Driver's License #

E-Mail

City

Employer

Occupation

Work Phone

Home Phone

State Zip

Ext. #

Cell Phone

4 Dental Insurance InformationPrimary Insurance

Name of Insured

Relationship to patient

Insured's birthdate

Social Security #

Employer

Date Employed

Occupation

Insurance Company

Group #

Ins. Co. Address

Deductible

Amount already used

Max. annual benefit

5 Authorization and Release

Additional InsuranceName of Insured

Relationship to patient

Insured's birthdate

Social Security #

Employer

Date Employed

Occupation

Insurance Company

Group #

Ins. Co. Address

Deductible

Amount already used

Max. annual benefit

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinationrendered to me or my child during the period of such Dental care to third party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwisepayable to me.

I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible forpayment of all services rendered on my behalf or my dependents.

Signature of patient or parent if minor Date

••Hi

Financial ArrangementsI understand that I am responsible for any and all account balances

for treatment rendered. I am also aware that if I have dental insurance,it will be submitted for me only if adequate information is provided.

Late ChargesIf I do not pay the entire new balance within 90 days of

the monthly billing date, a late charge of 1.5% on thebalance then unpaid and owed will be assessed eachmonth (if allowed by law). I realize that failure to keep thisaccount current may result in you being unable to provideadditional dental services except for dental emergencies orwhere there is prepayment for additional services. In thecase of default on payment of this account, I agree to paycollection costs and reasonable attorney fees incurred inattempting to collect on this amount or any futureoutstanding account balances.

Thank you for filling out this form completely. The information you have provided will help us serveyour dental healthcare needs more effectively and efficiently. If you have any questions at anytime,

please ask - we are always happy to help. FORM 155318 R/01/12 ITEM 8101

JLJLVCULULINAME BIRTHDATE TODAY'S DATE

A Medical History

1.

2.3.

5.

YES NO

Have there been any changes in yourgeneral health within the past year? G GDate of your last physical exam:Physician's nameAddressPhone No.Have you ever been hospitalized forany surgical operation or serious illness? G OPlease explain.

Are you taking any medicine(s)including non-prescription medicine? G GIf yes, what medicine(s) are you taking? Please list.

6. Do you take Aspirin daily? O D7. Have you had any abnormal bleeding? G G8. Do you bruise easily? G O9. Have you ever required a blood

transfusion? G G10. Have you had a recent weight loss? G G11. Do you use tobacco? n G12. Do you use alcohol? G O13. iDo you use controlled substances? G G14. Are you wearing contact lenses? G D15. IDo you regularly take dietary

supplements or herbal medication? G G

If yes, do you regularly take:

G Garlic G Ginger G Ginseng G Ginkgo BilobaO Ephedra O KABA O St. John's Wort O ValerianWomen Only:

1. Are you pregnant or thinkyou may be pregnant? G G

2. Are you nursing? G G3. Are you taking birth control pills? G G

Are you allergic to or have you had reactions to:1. Local anesthetics like novocaine? G G2. Penicillin? O O3. Sulfa drugs? O O4. Other Antibiotics? O O5. Barbiturates, sedatives or sleeping pills? G G6. Aspirin? G G7. Iodine? O O8. Other?

YES NODo you have or have you ever had the following:

1. Rheumatic heart disease or rheumatic fever?.. O G

2. Scarlet fever? O O

3. Heart defect or heart murmur? G G

4. Heart trouble, heart attack, or angina? G G

a. Do you require extra pillows

when you sleep? G

5. Pacemaker? G

6. Heart surgery? O

7. High blood pressure? G

8. Low blood pressure? O

9. Hepatitis, jaundice or liver disease? G

10. Stroke? O

11. Sinus trouble? O

12. Lung or breathing problems? G

13. Asthma or hay fever? G

14. Hives or skin rash? G

15. Fainting spells or seizures? G

16. Diabetes? O

17. AIDS or HIV infection? O

18. Thyroid problems? G

19. Allergies? O

20. Arthritis or rheumatism? G

21. Joint replacement or implant? G

22. Stomach ulcer? O

23. Kidney trouble? O

24. Tuberculosis? G

25. Persistent cough? G

26. Cough that produces blood? G

27. Cancer? O

28. Sexually transmitted disease? G

29. Epilepsy? O

30. Anemia? O

31. Leukemia? O

32. Glaucoma? O

33. Do you have any disease, condition or

problem not listed above that you think

I should know about? , ., G

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

G

O

G

O

O

O

O

O

G

O

O

G

O

G

B1.2.3.4.

5.6.7.

9.

10.

11.

12.

Dental History

Reason for visit:When was your last dental visit?How often do you brush your teeth?What texture brush do you use? D Soft Medium D Hard

YES NODo your gums bleed while brushing? O O 13.Do your gums bleed when flossing? D ODo you feel pain to any of your teeth 14.when brushing or flossing them? D Ll 15.Are your teeth sensitive to hot, cold,sweet or sour foods/liquids? D L) 16.Have you noticed any loosening of 17.your teeth? O aDoes food tend to become caughtbetween your teeth? D DDo you have any sores or lumps in ornear your mouth? O OHave you ever experienced any of the 18.following problems in your jaw?

a. Clicking? O O 19.b. Pain (joint, ear, side of face)? D Dc. Difficulty in opening or closing? O D 20.d. Difficulty in chewing? D G

YES

Have you had any head, neck, orjaw injuries? DDo you have frequent headaches? DDo you clench or grind your teethwhile awake or asleep? DDo you bite your lips or cheeks frequently? DHave you ever had:

a. Orthodontic treatment (braces)? Db. Oral surgery? Dc. Gum treatment? Od. Your teeth ground or the bite adjusted? .. De. Worn a bite plane or other appliance?.... D

Are you satisfied with the appearanceof your teeth? DHave you ever had an upsettingexperience in the dental office? DIs there anything about having dentaltreatment that bothers you? D

NO

a

a

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrectinformation can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes inmedical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

FORM 111710 R/01/12 ITEM 8101