If this is your own policy:

Is this through an employer?

Employer:____________________________________________

Insurance Co._________________________________________

ID #_________________________________________________

Policy #______________________________________________

Group #______________________________________________

If you are on someone else’s policy (parent, spouse, etc.):

Subscriber's Name______________________________________

Relationship to Patient__________________________________

Subscriber's Birthdate ___________________________________

Subscriber's SSN_______________________________________

Is this through an employer?

Insurance Co._________________________________________

Employer:____________________________________________

Policy #______________________________________________

Group #______________________________________________

Today’s Date __________ Patient Name (last, first, middle initial) ________________________________________

Preferred Name _________________________ Gender __________ Marital Status ______________________

Birthdate _____________ SSN _______________ Employer/School __________________________________

Prefer contact by: email phone call text

How did you hear about us? ___________________________________________________________________

Home Phone (____) _________________ Street Address ___________________________________________

City __________________ State _____ Zip ___________ Cell Phone (____) ___________________

Work Phone (____) ___________________ Email Address __________________________________________

IN CASE OF EMERGENCY, CONTACT (If possible, specify someone who does not live in your household.)

Name ______________________________________ Relationship ___________________________________

Phone ( _______ ) ____________________________ Alt. Phone ( _______ ) ___________________________

Yes No

___________________________________________________________________

Signature of Patient, Parent, Guardian or Personal Representative

___________________________________________________________________

Please print name of Patient, Parent, Guardian or Personal Representative

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with ___________________________________________________ (Name of Insurance Company[ies])

and assign directly to Smiles for Life all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all

charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-mentioned dentist may use my health care information and may disclose such information to the above-mentioned Insurance Company(ies) and their agents for

the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is

completed or one year from the date signed below.

Do you have dental insurance?

Yes No

Yes No

Patient Name __________________________________________________ Nickname ______________________________ Age ________

Name of Physician/and their specialty __________________________________________________________________________________

Most recent physical examination_______________________________________ Purpose _______________________________________

What is your estimate of your general health? ⃝ Excellent ⃝ Good ⃝ Fair ⃝ Poor

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your

dental treatment (e.g., Botox, Collagen Injections)

_________________________________________________________________________________________________________________

List all medications, supplements, and/or vitamins taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient’s Signature __________________________________________________________________________ Date __________________

Doctor’s Signature __________________________________________________________________________ Date __________________

Do you have or have you ever had:

1. alcohol/recreational drug use________________________ 2. an allergic reaction to______________________________

⃝ Aspirin, ibuprofen, acetaminophen, codeine ⃝ Erythromycin ⃝ Fluoride ⃝ Latex ⃝ Local anesthetic ⃝ Metals (nickel, gold, silver, ____________) ⃝ Penicillin ⃝ Sulfa ⃝ Tetracycline ⃝ Other _____________________________

3. anemia or other blood disorder_______________________ 4. antidepressant medication___________________________ 5. arthritis__________________________________________ 6. artificial heart valve, repaired heart defect (PFO)_________ 7. asthma__________________________________________ 8. autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)___________ 9. breathing or sleep problems (e.g., sleep apnea, snoring, sinus)_____________________ 10. chemotherapy, immunosuppressive medication_________ 11. contact lenses_____________________________________ 12. diabetes (HbA1c=______)___________________________ 13. digestive disorders (e.g., celiac disease, gastric reflux)_____ 14. emotional difficulties_______________________________ 15. emphysema, shortness of breath, sarcoidosis____________ 16. epilepsy, convulsions (seizures)_______________________ 17. glaucoma________________________________________ 18. head or neck injuries_______________________________ 19. heart problems or cardiac stent within the last six

months__________________________________________ 20. hepatitis (type ______)_____________________________ 21. high cholesterol or taking statin drugs__________________ 22. high or low blood pressure___________________________ 23. HIV/AIDS_________________________________________ 24. hives, skin rash, hay fever___________________________ 25. hormone deficiency________________________________

26. hospitalization for illness or injury___________________ 27. history of infective endocarditis______________________ 28. an inhaler, nitroglycerin, an epi pen, or glucometer?

If yes, bring to all appointments______________________ 29. jaundice_________________________________________ 30. kidney disease____________________________________ 31. liver disease______________________________________ 32. any lumps or swelling in the mouth____________________ 33. neurologic disorders (ADD/ADHD, prion disease)_________ 34. orthopedic implant (joint replacement)________________ 35. osteoporosis/osteopenia (e.g., taking bisphosphonates)___ 36. pacemaker or implantable defibrillator_________________ 37. prolonged bleeding due to a slight cut (INR > 3.5)________ 38. psychiatric treatment_______________________________ 39. radiation therapy__________________________________ 40. rheumatic or scarlet fever___________________________ 41. STI/STD/HPV______________________________________ 42. stomach or duodenal ulcer__________________________ 43. a stroke (taking blood thinners)_______________________ 44. thyroid, parathyroid disease, or calcium deficiency_______ 45. tuberculosis, measles, chicken pox____________________ 46. tumor, abnormal growth____________________________ 47. viral infections and cold sores ________________________ Are you: 48. aware of a change in your health in the last 24 hours

(e.g., fever, chills, new cough, or diarrhea)______________ 49. taking birth control pills_____________________________ 50. taking dietary supplements__________________________ 51. often exhausted or fatigued_________________________ 52. experiencing frequent headaches_____________________ 53. currently pregnant_________________________________ 54. diagnosed with prostate disorders____________________ 55. a smoker, smoked previously or use smokeless tobacco___ 56. considered a touchy/sensitive person__________________ 57. often unhappy or depressed_________________________ 58. taking medication for weight management_____________ 59. presently being treated for any other illness____________

YES NO YES NO

Drug

_______________________

_______________________

_______________________

Purpose

____________________________

____________________________

____________________________

Drug

_______________________

_______________________

_______________________

Purpose

____________________________

____________________________

____________________________

ASA ______ (1—6)

Name ___________________________________________________ Nickname__________________________ Date ____________

Age _______ Referred by ____________________________________ Previous Dentist ____________________________________

Date of most recent dental exam ____________ Date of most recent x-rays ____________

Date of most recent treatment (other than a cleaning) ____________

I routinely see my dentist every [circle one]: 3 months, 4 months, 6 months, 12 months, Not Routinely

What is your immediate concern?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Personal History

Are you fearful of dental treatment?

Have you had an unfavorable dental experience or complications from past dental treatment?

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Did you ever have braces, orthodontic treatment, or had your bite adjusted?

Have you had any teeth removed or missing teeth that never developed?

Gum and Bone

Do your gums bleed or are they painful when brushing or flossing?

Have you ever been treated for gum disease, been told you have lost bone around your teeth, or have anyone with

a history of periodontal disease in your family?

Have you ever noticed an unpleasant taste or odor in your mouth?

Have you ever experienced gum recession?

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating hard,

dry foods (apples, chewing gum, carrots, nuts, bagels, etc.)?

Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Tooth Structure

Have you had any cavities, broken or chipped teeth, grooves near the gum line, or a toothache or cracked filling?

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

Yes No

If you could whiten your teeth for a cost anyone could afford,

would you do it? _____________________________________

Do you smoke or use chewing tobacco? How much? For how

long? ______________________________________________

If you could change your smile, you would:

[ ] Make them brighter

[ ] Make them straighter

[ ] Close spaces

[ ] Replace black metal fillings with natural, tooth-colored

fillings

[ ] Repair chipped teeth

[ ] Replace missing teeth

[ ] Replace old crowns that don’t match

[ ] Have a smile makeover

How important is your dental health to you? 1-10 __________

Where would you rate your current dental health? 1-10 _____

Why did you leave your previous dentist? ________________

___________________________________________________

What is the most important thing to you about your future

smile and dental health? ______________________________

___________________________________________________

What is the most important thing to you about your dental

visit today? _________________________________________

___________________________________________________

Bite and Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping).

Do you have more than one bite, have to squeeze or shift your jaw to make your teeth fit together, or feel like your

lower jaw is being pushed back when you bite?

Have your teeth changed in the last 5 years, become shorter, thinner, or worn?

Are your teeth becoming more crooked, crowded, or overlapped?

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Do you clench your teeth in the daytime or make them sore?

Do you have any problems with sleep (i.e., restlessness) or wake up with a headache or an awareness of your teeth?

Have you ever worn a sleep device?

Do you wear or have you ever worn a bite appliance?

Cavity Risk

Do you take medications daily? If so, how many?

Do you feel as though you have a dry mouth at any time of the day or night?

Do you drink liquids other than water more than 2 times daily between meals?

Do you snack daily between meals?

Do you notice plaque build-up on your teeth between brushings?

Patient Signature _________________________________________________________________________ Date ____________

Doctor Signature _________________________________________________________________________ Date ____________

Yes No

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights

section describing your rights under the law. You have the right to review our Notice before signing this consent by requesting a copy from the receptionist. The terms of our

Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. You have

the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior

Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

Protected health information (PHI) may be disclosed or used for treatment, payment, or healthcare operations

The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice

The Practice reserves the right to change the Notice of Privacy Practices.

The patient has the right to restrict the use of their information, but the Practice does not have to agree to those restrictions

The patient may revoke this Consent in writing at any time and all future disclosures will then cease

The Practice may condition treatment upon execution of this Consent.

Below is a list of ways the office may contact you. Checking the first box will give permission to leave as thorough of a message as needed

from your dental office. This will include, but is not limited to, appointments day, time, and treatment scheduled; documents to be signed;

financial and collection concerns; or pre– and post-treatment directions. Any source other than the USPS, example: cell phones, email, and

fax lines, are not considered 100% secure. Contact information will be verified by patient.

_____ Patient gives office permission to use any contact written on patient registration form.

Please check any that you DO NOT want the office to call. We will be using the numbers/emails you have updated on your Account

information. All information is subject to availability to verify and validate.

List names of who can have access to your dental chart information. Circle type. If Partial, state what part of your chart (Financial,

Treatment, and/or Health History) is allowed to be disclosed or copied.

__________________________________________ Full access / Partial access __________________________________________

__________________________________________ Full access / Partial access __________________________________________

__________________________________________ Full access / Partial access __________________________________________

_____ Patient gives office permission to forward any verified contact information and PHI to patients specialists. Office may discuss pertinent patient chart information,

including PHI, with labs, and product representatives involved in patient’s case through verified, unsecured, unsecured, unencrypted means. The Privacy Rule allows those

doctors, nurses, hospitals, laboratory technicians, and other healthcare providers that are covered entities to use or disclose protected health information, such as x-rays,

laboratory, and pathology reports, diagnoses, and other medical information for treatment purposes without the patient’s authorization. This includes sharing the

information to consult with other providers, including providers who are not covered entities, to treat a different patient, or to refer the patient. See 45 CFR 164.506. Any

source other than your Healthcare Providers will sign a Business Associate Agreement. Patient understands if permission is not granted, USPS is the only means of

communication with those involved in patients case, which is considered HIPAA compliant. Treatment may take considerably longer in this case. This office will not be held

responsible for any delay in mail which then causes an increase in treatment time or treatment costs. Patients or approved contacts may request and pick up copies of PHI to

be hand delivered.

Print Patient’s Name: ______________________________________________________________ Date: ____________________

Print Legal Guardian’s Name: _______________________________________________________ Date: ____________________

Signature of Patient or Legal Guardian: ________________________________________________ Date: ____________________

____ Patient refused to sign HIPAA Consent. Patient has the right to refuse. USPS or patient pick up will be used for PHI transfer.

Office Staff Signature: ______________________________ Printed Name: ___________________________ Date: __________________

Witnessed Staff Signature: __________________________ Printed Name: ___________________________ Date: __________________

___ Work Cell

___ Personal Cell

___ Emergency Contact

___ Work Phone

___ Home Phone

___ Interpreter Contact

___ Work Email

___ Home Email

___ Work Fax

___ Home Fax

___ Mail to Work

___ Mail to Home

___ Any of the above