PATIENT REGISTRATION

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1 ID: First Chart ldr Patient ls: I Policy Holder I Responsible Party -Responsible Party (if someone other than the patient) PATIENT REGISTRATION Last Preferred Middle lnitial: First Last Middle Initial: City, State, Zip: Home Phone: Birth Date: Work Phone: Soc Sec: Ext: Drivers Lic: Pager: O Responsible Party is also a Policy Holder for Patient Q erimary Insurance Policy Holder O Secondary Insurance Policy Holder City: State / Zip: Pager Home Phone: Work Phone: Ext: Cellular: Sex: e n/late Q Female Marital Status: Q Married Birth Date: _ Age: Soc. Sec: Q Singte Q Divorced Q Separated Q widowed Drivers Lic: Section 2 Employment Status: Q futt Time Student Status: Q fuil Time Medicaid ld: Employer ld: Canier ld: Q eart time Q Part Time Pref. Dentist: Pref. Pharmacy; Pref. Hyg.: Q Retireo f-l I would like to receive correspondences via Section 3 Emergency Contact: Emergency Phone: Refened By: Previous Dentist: r Primary Insurance Information Name of Insured: Relationship to Insured:O Sef Q spouse Q crrito Q otner Insured Soc. Sec: Insured Birth Date: Employer: Ins. Company: I City,State,Zip: I Rem. Benefits: I ; Secondary Insurance Information I Name nf of lncrrrcd' Insured: Insured Soc. Sec: Employer:.00 Rem. Deduct: ; city,state,zip:.00 Insured Birth Date: Relationship to Insured:Q Self Ins. Company: Q spouse Q cniu Q ottrer City,State,Zip: Rem. Benefits: 00 Rem" Deduct: 00 City,State,Zip:

2 Alpine Family Dental 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 e;-" t"tr"*n Oro*"* 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 ves Q tto Have you ever been hospitalized or had a major operationz Q Ves Q ruo Have you ever had a serious head or neck injury? Q Ves Q tto Are you taking any medications, pills, or drugs? Q Ves Q Do you take, or have you taken, Phen-Fen or Redux? Q Ves Q fuo Have you evertaken Fosamax, Boniva, Actonel or any,,., other."medications containing bisphosphonatssi (, ^ Yes L) Are you on a special diet? Q Yes Q Do you use tobacco? Q ves Q Do you use controlled substances? Q ves Q Are you allergic to any of the following?..** Women: Are you! Pregnant/Trying to get pregnant?! taking oral contraceptives?! Aspirin! Penicillin! Codeine! Acrylic! vtetat ;,;;; I Local Anesthetics I sura Drugs I Ottrer f Nursing? n AtDS/Htv Positive n Alzheimer's Disease! Anaphylaxis! Anemia f, Angina I Arthritis/cout f, Rrtiticiat HeartValve f nrtiticiat Joint I astnma I Blood Disease I aooo Transfusion f Breathing Problem L l tsrurse casily I cancer f Chemotherapy f Chest Pains! Frequent Headaches! coto Sores/Fever Blisters E Genital Herpes! Congenital Heart Disorder I claucoma! Convulsions I Hay Fever! Cortisone Medicine! HeartAttacuFailure! oiabetes! Heart Murmur I Drug Addiction! Heart Pacemaker n EasilyWinded! Heart Trouble/Disease I Emphysema n Hemophilia I Epilepsy or Seizures n Hepatitis A! Excessive Bleeding n Hepatitis B or C I ExcessiveThirst I Herpes I fainting Spells/DizzinessI Hign Blood Pressure I Frequent Gough f Hign Cholesterol f Frequent Diarrhea I Hives or Rash Haveyoueverhadanyseriousillnessnotlistedabove?Q YesQ lf yes,pleaseexplain:! Hypoglycemia! lrregular Heartbeat! xioney Problems! Leukemia! Liver Disease I Low Blood Pressure f Lung Disease tr Mitral Valve Prolapse! Osteoporosis! eain in Jaw Joints! Parathyroid Disease I Psychiatric Care! Radiation Treatments n Recent Weight Loss n Renal Dialysis! Rheumatic Fever n Rheumatism! Scarlet Fever! Sningles! sicrte cett Disease n sinus Trouble n Spina Bifida n Stomach/lntestinal Disease f, strot<e.l I Swelling of Limbs n Thyroid Disease E Tonsillitis! Tuberculosis! Tumors or Growths! ulcers! Venereal Disease n Yellow Jaundice 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. lt is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT. PARENT. or GUARDIAN DATE

3 Alpine Family Dental 101 Westview Park Place Kalispell MT (406) DENTAL ANXIETY SCALE This form is designed to inform us of your individual needs, so you may have a comfortable, pleasant experience in our office. Please choose the most appropriate answer: 1. If you had to go to the dentist tomorrow, how would you feel about it? A) I would look forward to it as a reasonable, enjoyable experience. B) I wouldn t care one way or the other. C) I would be a little uneasy about it. D) I would be afraid that it would be unpleasant and painful. E) I would be very frightened of what the dentist might do. 2. When you are waiting In the dentist s office for your turn in the chair, how do you feel? 3. When you are in the dentist s chair, waiting while he gets his drill ready to begin working on your teeth, how do you feel? 4. You are in the dentist s chair to have your teeth cleaned. While you are waiting and the hygienist is getting out the instruments that will be used to clean your teeth around the gums, how do you feel? On a scale of 0 to 10, where 0 is so relaxed you could fall asleep and 10 is the point when you are so fearful you might faint, become sick, or run out of the treatment room, please rate the flowing: 1. Sitting in the dental reception room 8. Have a tooth drilled 2. Smelling the smell of a dental office 9. Seeing the dental probes or instruments 3. Sitting up in a dental chair 10. having the dental instruments manipulated 4. Reclining in a dental chair in your mouth 5. Seeing the needle and syringe for anesthesia 11. The dentist walks into the treatment room 6. Receiving the anesthetic injection 12. Having your teeth cleaned 7. Hearing the noise of the dentist s drill 13. Having dental x-rays taken Have you ever experienced nitrous oxide (gas) in a dental office? Yes Your Today s date: Dental Anxiety Scale

4 Financial and Appointment Agreement Alpine Family Dental 101 Westview Park Place Kalispell, MT I understand that I am financially responsible for all services rendered at this office. I hereby authorize Gregory D. Eller DMD PC (dba Alpine Family Dental) to affix my name to all insurance submissions, documents, and/or information requested by company(s) relating to any health benefits due to my dependents and myself. I authorize insurance payments to be sent directly to this office. I understand that if insurance sends payment to me directly, I am required to pay at the time services are rendered. I agree to be held responsible for all charges and services not paid by my insurance company. Should my account become delinquent I will be held responsible for all costs associated with collection including collection agency fees. I also authorize the use of any information provided by me on my patient registration form to secure payment from insurance companies or collection agencies. I understand that when I schedule an appointment it is reserved exclusively for me and I assume the responsibility to maintain my appointment. If I am unable to maintain my appointment I understand that I'm required to give a 48 hour notice of cancellation. If I arrive late I understand I may not be seen that day and my tardiness will be considered a short notice cancelled appointment. I understand if I am habitually late, miss or short notice cancel appointments, I may be dismissed from the practice. showed or short notice cancelled appointments may result in a $50.00 broken appointment fee. Phone call, Text Message and reminders are solely a courtesy. Please select how you would like to receive your courtesy reminder: Phone call Text Message Signature of patient or responsible party: Date:

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Alpine Family Dental Gregory D. Eller, DMD PC You may refuse to sign this acknowledgement but, in refusing we will not be allowed to process your insurance claims. Date: The undersigned acknowledges receipt of a copy of the currently effective tice of Privacy Practices for Alpine Family Dental (Gregory D. Eller, DMD PC). A copy of the signed, dated document shall be effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS IN THE FUTURE. Please print patients/your name Please sign your name Legal guardian Relation to patient PLEASE LIST ANY OTHER PEOPLE WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION: (This includes spouse, partner, step parents, parents (when patient is over age 18), grandparents and any care takers who can have access to this patient's records): Special Requests: Office Use Only: As privacy officer, I attempted to obtain the patient's (or legal guardians) signature on this acknowledgement but did not because: It was emergency treatment I could not communicate with the patient The patient refused to sign The patient was unable to sign because Other (please describe) Signature of Privacy Officer

Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:

Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular: ID: PATIENT REGISTRATION DATE First Name: Patient Is: Policy Holder Responsible Party Last Name: Preferred Name: Middle Initial: Responsible Party (if someone other than the patient) First Name: Last Name: