nme 9:47 AM

Patient Name:

Chadwick Webster, D,D,S, Eaglesoft Medlcal Hlstory(copy}l

Birth Dare: Date Created:

Date 4/2S/21Jl7

Although dental personnel primardy 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 m11y be taking, c

Ate you under a physician's care now? Oves ONo If yes

H11ve you ever been hospllabzed or had a major operation? Oves ONo lfyes

Have you ever had a serious head or netk Injury? OYes QNo If yes

Ate you taking any medications, pills, or drugs? Oves ONo If yes.

Do you take, or have you taken, Phen-fcn or Redux7 Oves 0No If yes

Do you use tobacco? What type? Oves ONo If yes

Have you ever taken Fosamax, Bonlva, ActDnel or any other Oves ONo If yes medications containing bisphosphonates?

Do you experience dry mouth? How often? Oves ONo If yes

If you could change anything about your smile/teeth what Oves ONo If yes would ltbe?

Women: Ate you .. , OPregn�nt/Trylng 10 get pregnant? ONurslng? OTaking oral contraceptives?

Are you aDergic 10 any of the foDowlng? OAsplrtn OPenldllln Ocodelne OAaync OMe!al OLatex D Sulfa Drugs OLocal Anesthetic,

Other? D If yes

Do you have, or have you had, any of the following? AIOSfrllV Po'1tive Oves ONo Cortisone Medicine Oves QNo Hemophnia Oves QNo Radiation Treatments Ove:; QNo Alzheimer's Disease Oves ONo Diabetes QYes QNo Hepatitis A Oves QNo Recent Weight Loss Oves ONo Anaphylaxis OYes ONo Drug Addiction Oves ONo Hepatitis B or C Oves ONo Renal Dialysis OYes ONo Anemia OYes ONo Easily Winded QYes QNo Herpes Qves QNo Rheumatic Fever OYes ONo Angina Oves QNo Emphysema Oves ONo High Blood Pressure Oves ONo Rheumatism Oves ONo Arthritis/Gout QYes QNo Epilepsy or Seizures QYes QNo High Cholesterol Oves QNo SCZIJ'let Fever Oves QNo Artificial Heart Valve OYes ONo Excessive Bleeding Oves ONo Hives or Ras.h Oves ONo Shingles Oves ONo Artificial Joint Oves ONo Excessive Thirst Oves ONo Hypoglycemia OYes ONo Sickle Cell Disease Oves ONo

. Asthma OYes ONo Fainting Spells/Dinines.s OYes ONo Irregular Heartbeat QVes QNo Sinus Trouble Oves QNo Blood Disease Oves QNo Frequent Cough Oves ONo Kidney Problems Oves QNo Spina Biflda Oves QNo Blood Trensfusion Oves QNo Frequent Diarrhea Oves QNo Leukemia Oves QNo Slx>mach/lntestinal Disease OYes ONo Brea1hlng Problems QYes QNo Frequent Headaches Ores QNo Uvcr Olaca•c Qyc, QNo Stroke OYes QNo

Bruise Easily OYes ONo Genital Herpes OYes QNo Low Blood Pressure Oves QNo Swelling of Limbs Oves ONo Cancer Oves ONo Glaucoma Oves ONo Lung Disease Oves QNo Thyroid Disease Oves ONo Chemotherapy OYes ONo Hay Fever Oves ONo Mitra! Valve Prolapse Oves QNo Tonsillitis Oves QNo Chest Pains Oves QNo Heart Attzl�adure Qves QNo Osteoporosis QYes QNo Tuberrulosis OYe:; ONo Cold Sores/Fever Blis1ers Qves ONo Heart Murmur OYes ONo Pain In Jaw Joints Oves ONo Tumors or Growths OYes ONo . Congenital Heart Disorder Ores ONo Heart Pacemaker Oves QNo Parathyroid Disease Oves QNo Ulcers OVe:; ONo Convulsions OYes ONo Heart Trouble/Disease OYes QNo Psychiatric Care OYes QNo Venereal Disease Oves ONo Yellow Jaundice Oves QNo

Have you ever had any serious dlness not fisted above1 Oves ONo If yes

Comments: ARE YOU lNTcRESTED IN WHITER TEETH? Oves QNo If yes

· To the best of my knowledge, the quesUons on this furm have been accurately answered, I understand that providing Incorrect Information can be dangerous to my (or patient's) health, It Is myresponsibffity to Inform the dental office of any changes In medical status,

Signature of PaUent, Parent or Guardian:

X Date: ____ _

OEl'iTAI. CRf.ATIO�S Hy Cll,\ll\\'ICK \\'IWSTF:n. l>DS, l'C

8190 Snuth \lrmorinl l>rlvt Tulsn, Oklalwmu 74133

?l!!-307-0307

NOTICE Of PRIVACY PRACTICES

lnis notice Is to Inform you lhc,I your po,.onol health ;nro,mol.on wili only be v>od for pvrp0$8$ of lreotn1enl in our foclllly end wm not be milu,;ed or disclo1od by, 10 anyone oulsioo of our proclice. You moy gain access 10 lhis lnlormollon if you desire.

?leme review H corefully Tho privocy of your heollh lnlc,rmoHon is imporlonl lo us.

• Our Legal Duty

We oro required by opphcoble feucro1 ond )!Ole 1uw lo mointo,n the p,ivocy of your neollh lnlormotlon. We ore also reQulred 10 give you this n otice obout our privacy proctice1, our ,egol dulies. end your nghts concerning your heollh information. We must loUow lhe privacy proclice1 that me descr,oc:cJ in 1ni1 nohc.o wnil<:, ,111 In elfecl, This notice lol<es effect on April 1,4, 2003 and will remain in effect.

We reserve lhll righl lo change our pri,c,cy proclii;,., end tho farms of lhis nolice ol ony lime provided such changes ore permilled by oppttcoole low. Wa rcm1rve lhc righl lo moko the cnongos in our privocv proclice5 ond Ille new forms of ovr notice effective for oll heclltl informotion lhol we mcinlain. including hP.olth informalion we crooled or received before we mode tne chonges. aero,e we moite o slgniliconr change in our privacy practices, we will chance lhls notice and moke the new notice ov0,lab1e vpon requesr.

You may reQuesr a copy or our notice ol any lime. Fer more inlormolion obou1 our privacy practices, or for odditionol cople$ of !his nolice. please co111ocl us using lhe information listed ot the eno or this notice.

• Uses and Disclosures of Health Information

We use ond di1c1ose '1eolfh lnlormohon oooul y ou lor lreolmenl, paymen1. and hcoflhcore oporoliom. For example:

Treatment: We may use or disclose you1 neallh inlormolion to a physician or other healthcare provider wl10 11 currenlly provi ding rreormenl lo you.

Payment: We moy use and d;sclorn your h"ollh inro,motlon l o obloin payment for services we provide to you (I.e. insurance companies).

Healthcare Operations: w,, rnoy vm 011d discloso your health Information in conneclion wil11 our heolthcore operations. Heollhco•a operolion, incl11de quollty a,sonm.inl ond improvomont oclivilios, reviewing tho competence or ciuoliflr.aliom of henltht:nr,. profes.ionols, ovolvoting proclitionor end provider porforrnonco. conducting training programi. occredilotion, certiflcolion, licAnsing or c redentialing activities.

• Your Authorization

You mov give us wtillen authorizolion to use yovr hoollh inlormolion or 10 cJiscloio ii to anyone for ony purpose (e.g. o family member picldng un records. ref(>rTOI to dontol spocioli1I. etc.) If yuu givo u> on oulhoril.otion, you may revoke If In wrlUng of ony time. Your revocotton will not affect any use or discto,u,e permitlod by yovr authorization while ii was In effe,cl. Unlt:tss you give a wrillen oulhorizolion. we connol um or clisctose your 11eollh inlormolion for any reason except lhose described In this nollce.

• To Your Family end Friends

Wo mu11 dr:cloie your ht!ol lh inforrnolion lo you, m described In 11,e Policnl Rights section of lhis Notice. We may disclOse your heollh information lo a family· momb.:,r, frio11d or othor pe,1011 to lhe extent necessary lo help wilh your heollhcort1 or wilh payment for your heolthca1e, but only if you CJgree 1no1 wr, moy dil 10

• Persons Involved In Care

We may uso or disclose heallh ir1formo1ion lo notify, or 011isl in 11,e nolificolion of (included identifying or locCJ'llng) o family member, your pe11onol representative or another pe1son rc,:pon1itJle for your coro, of your location, your general condilion. or dt1olh .. If you are present. then prl01 lo u�e or di:cro�uro or your hoallh inlormolion. we will provide you with on opporrunily 10 objecr lo such u1es of disclosures. In lhe event of your incopocily or emergency ci1cumslonccs. we will �closo health !nforrnolion bo1ed on a delermlnotlon using our professional ju,1oment disclosing only heoilh Information lhal i1 directl y relevanl to that person's involvemenl In your heoflhcare. we will olso use our orofessionol )udgmenl end our experience wilh common practice lo moke reosonoble Inferences or YOl" best Interest in allowing o person to pick up filled prescrlplions. medico! suppUes. x-roys, OI other 1i1n;1or forms of health informohcn.

Dental Creations by Chadwick Webster D.D.S., P.C. 8190 S. Memorial Dr.

Tulsa, OK 74133 (918)307-0307

Right to Refuse Service Policy

We appreciate your Interest and visit to our office today. As always, our goal Is to provide you and your family with exceptional dental care and treatment, while making you feel at home and comfortable. We understand that you have a choice when it comes to choosing a doctor and office, and we are thrilled that you have chosen Dental Creations to help meet those needs.

However, Dental Creations reserves the right to refuse service to anyone who is disrespectful, vulgar, or aggressive towards our doctor or any members of our staff. It would be with great regret, if such actions would have to be taken, but negative behavior will not be tolerated to any degree.

By signing below, I acknowledge the statement above.

Patient: ____________________ _ Date: _____ _