REGISTRATIONPATIENT:

FIRST: MI: LAST: PREFER:

ADDRESS:

HOME #:

CITY: ST: ZTP:

WORK #:

SS#:

CELL #:

BIRTHDAY: SEX: M F

MARRIED/ SINGLE / DIVORCED i SEPARATED / WIDOWED

EMPLOYER: SPOUSE/PARENT: PHONE #:

E-MAIL: TEXT MESSAGES? YES OR NO

LAST DENTAL VISIT: DENTIST: PHONE#:

LAST X-RAYS: LAST CLEANING: LAST TREATMENT

HOW DID YOU HEAR ABOUT OUR OFFICE? Wu offe* Rr.ferr*L Rr,v,ta+d,tl!FRIEND/FAMILY: WEBSITE: OTHER:

iN CASE OF AN EMERGENCY:NAME: RELATION: PHONE:

INSTJRANCE:EMPLOYER: PHONE #:

ADDRESS: CITY: ST: ZIP:

PRIMARY INSURANCE COMPANY:POLICY HOLDER

ID#INSURED SS# BIRTHDAY

SECONDARY INSURANCE COMPANY: TD#

POLICY HOLDER INSURED SS# BIRTHDAY

RESPONSIBLE PARTY:RELATIONSHIP TO PATIENT: Self / Spouse / Child / Other

FIRST: LAST:

ADDRESS:

HOME #:

ST: ZIP:

WORK #:BIRTHDAY: SS#:

CITY:

CELL#:

MI:

AlEhouqhdentalpersonnel prinurilftreattheareainandaroundyourmouth,yourrnorlthisapartofyourentirebody. HealEhprablemsthatyournayharre,or

Prtient Name:

Are you under a physiclan's caFe nou..? If so, Whoand Why?

Hdve you ever been hospitalized or had a nrajoroperation?

H.ve you ever had a ssrlous head or neck inj$ry?

Are you taking any medicatfons, pills. cr dftJgs? Ifyes, Iist.

Do you take, or have you taken, Pheft-Fen or Redux?

Have you ever taken Fosarna>; Boftiva, Actonel orany other medications containing bisphosphonates?

Are you on a .speci.af diet?

Do you use tobacco?

Do you use controlled substances?

Any trdvel outside the U.S. in the tast 30 days?

V{omen: Ar€ you.,.

i'i Rregnantflrying to gst pregnant?

Are you allergic to any of the follo$ring?

lllAspirlnlil u"tat

Other?

ElEon DentistryEaglesoft M€dkal History(Coplr)

Eirth Date: Date Cr€ated:

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ffx Yes {j, No Ifyes

H)Takfng oral contraceptiv€s?

Hl Penicillln

ffi)Latex

ir.-.1

Cortison.e [,ledicine \* Yes s:) No

Di:abetes *l Yes q) t'loDrug Addiction {i} Yes gi No

Easity Winded $ Yes {9 t'to

Emphysema ql) Yes * No

Epitepsf or seizures () Yes * l'lo

Excessive Bteediag 0 Yes €J l'lo

Excessive Thirst ($ Yes q+ lloFainUng Spells/Diainess # Yes # No

Frequent Cough * Yes *) l'loFrequent Diarrhea # Yes $ No

Frequ,ent Headaches (l1 Yes (S No

GenitBl Herpes f;'1 YBs *l) No

Glaucoma #Yes #l',loHay Fever (9 Yes ff;i t{o

H€art Attack/Faiture 13) Yes {? ruo

Heart Murmur {} Yes ffi tloHeart Pacemaker S Yes €) No

Heart Troubte/Disease ffi Ye-s ('.} No

HI codeineffi sura Drug.s

rr*'[-* --" -:-_: " :

ffiecrylicl*i Local Anesthetics

Do you have, or have you had, :ny of the folloyring?

AIDS/HIV Positive {r Yes e) No

Alzheimer's Disease t{i Yes i$ NoHemophilia (:l] Yes ii,S No

Hepatitis A {} Yes {-a} No

Flepatitis B or C f'J Yes e) No

Herpes f,) Yes $ t'lo

High Blood Pressure S Yes r.) f'lo

High Ch,olesterol {* Yes t} No

Hives or Rash $ Yes {.Y No

Hypoglycemia {i} Yes do} t'lo

Irr€gular Hedrtbeat .s Yes # I',lo

Kidney Probtems f,}Yes m I'loLeukernia f'l+ Yes S No

Liver Disea.s€ 41 Yes $ No

Low Efood Pressure f*) Yes {-} No

Lung Disease ,*$ Yes f: No

Mitrat valve Prolapse e Yes q$4, l'lo

ostecporosis {:} Yes 8t l',lo

Paln in Jaw lotnts t, Yes * t{o

Parathyrold Disease # Yes f) No

Psychiatric Care f! Yes (* No

RadiEtion Treatm€ntsR€cent Weight Loss

Renal Diatysis

Rheumatic Fever

Rheumatism

Scartet Fever

Shingles

Sickle C€ll Diseas€

sinuE Troublespinn BifidoStomdchIntestinal Disease

Stroke

Svuelling of Limbs

Thyroid Disease

TonsillitfsTuberculosisTumors or Growths

Ulcers

V€nereal D[s€a5e

{} Yes + I'lo

* Yes ,:.1) No

{:} Yes 'ii) No

{:.!} Ye,s {,} tlo(.* Yes {:; No

{i Yes (i} flo(i} Yes () l'.lo

(} Yes q: I'lot) yes {i1 t-lo

fr!Yes{}I'lotj Yes (t:i No

{,) Yes i+ No,I) Yes ("1 No

,il)' Yes i.:) t'lo,lll) Yes {:i Flo

t) Yes t'.'j I',lo

r*) Yes iili l'.lo

{,:i Yes ,:j l.lo

qt Yes i,t'i No

Artificial Hedrt Valve g) Yes g] tloArtificial loint SYes$NoAstl'rma i"i,} Yes fl No

Blood Dlsease +1":.) Yes f-} No

Blood Transfusion (li Yes ('} l',lo

Breathing Problems () Yes ?,Y No

Anaphylaxis

Anemid

Angina

Arthritis/Gout

Bruise Easily

Ca.ncer

Chemotherapy

Chest Pains

Convufslons

Yeltorr,r laundice

ti:) Yes f,j} l,lo

{.} Yes f} No

{} Yes f;:, t,lo

,f: Yss et l,lo

€l Yes 0$ No

!:.':, Yes (;:) No

ii) Yes (1.) No

tlr Yes (} f'to

{) Yes 4j I'lo$ Yes $ I'lo"

Cold Sores/Fel er Blisters *i Yes e, No

Congenitzl HeartDisorder i-;:.t Yes t) No

Have you ever had any serlous tllftess not ttsted

Comments?

E\isting PatienLs

UpdBte Address?

Update phone number?

Update InsuranceT

Update Employer?

Ifyes I i

lr yes I

f ves [ --------------

If ves I I

IfYes|*:*g*-**&*Y-.-!'*-**-*._*-*.*...1

(:i Yes q) l,lo

fl) Yes qr, Po

'f) Yes €) r'to

({} Yes e} llo

S Yes (S tlo

(* Yes e) I.lo

To the bBst of nry knowledge, the questions on thE 6orm have been accuratev answered. I underst*nd that prwiding incorre(t information can bB dangerous ta rny (orp?tient's)health, Itisnryresponsibilltytoinformthedenta:l officeofanychangesinmedical status.

Signafure of Patient, Parent or GuBrdian:

X Date:

BLISON DBNTISTRYN. TYLER ELISON, DDS

1555 Lincolno Jerome, Idaho 83338 o 208-644-9166

We are committed to providing you with the best possible care. If you havedental insurance, we will help you maximize your allowable benefits.

Please ({ ) the option(s) most convenient for }rou to settle your account:

tr Cash/Check/Debit flVisa lMastercard trAm Expressfl Discover

E Care Credit(please see receptionist for applicationform)

Due to the constantly changing insurance contracts, benefits, and deductibleswe are only able to ESTIMATE your insurance coverage. As a courtesy to

you, we will file your insurance claim at no additional charge. A11 out ofpocket portions, including deductibles, are due in FULL at time of service.

In consideration of treatment by the doctor, I, undersigned, jointly andseverally, understand and agree:

o To be responsible for all fees relative to the professional servicesrendered under this agreement, that this may include me, myfamily, or other individuals that I authorize. I recognize thatinsurance is a contract between the patient and the insurancecompany, and I agree that I will pay all charges under thisagreement regardless of my insurance coverage. I may terminatemy responsibility under this agreement by paying my account infull and giving written notice to the doctor.

o To pay interest at the rate of 18% on all monthly balances over 60days from the original due date. Unless prior paymentarrangements have been made"

. Will be responsible if account goes to collections for all court costsand attorney fees.

Responsible Party Signature Date

ELISON DENTISTRYHIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected healthinformation. These rights are given to me under the Health Insurance Portability and

Accountability Act of 1996(HIPAA). I understand that by signing this consent, Iauthorize Silver Creek Dental to use and/or disclose my protected health information tocarry out the followi'Bir.utrrr.nt

which includes direct and/or indirect treatment by otherhealthcare providers involved in my treatment.Obtaining payment from third party payers, i.e. my dental and/ormedical insurance company/companies.

rhave",,";,,]l;,:il::i?:"1t,J|;#ilIi?fitr;ll"Jf :"J3:,lf 1".'"";,",your Notice of Privacy Practices, which contains a more complete description ofthe uses and disclosures of my protected personal health information, and myrights under HIPAA" I understand that you reserve the right to change the terms ofthis notice from time to time and that I may request the most current copy of thisnotice. I understand that I have the right to request restrictions on how myprotected health information is used and disclosed to carry out treatment, paymentand healthcare operations, but that you are not required to agree to use theserequested restrictions. However, if you do agree, you are then bound to complywith this restriction. I understand that I may revoke consent, in writing, at anytime. However, any use or disclosure that occurred prior to the date I revoke thisconsent will not be affected.

Signature Date

If signing on behalf of someone, explain your relationship to the patient:

. If you would like a copy of our HIPAA policy please ask the receptionist.

Patient refused or was unable to sign. Good faith effort was made to obtainacknowledgement of receipt.Describe reason of refusal:

Offi ce Personnel S ignature Office Personnel Name

Office Personnel Title Date