PATIENT S NAME GENDER First Middle Init. Last Male/Female. Home Address. PATIENT EMPLOYER Bus. Phone. Employer Address. NAME OF SPOUSE Birth Date

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1 PATIENT INFORMATION RECORD The following information is needed for our records. Please print answers to all questions. PATIENT S NAME GENDER First Middle Init. Last Male/Female Birth Age Marital Status Social Security No. Home Phone Cell Phone Address Home Address Street City/State/Zip PATIENT EMPLOYER Bus. Phone Employer Address City/State/Zip NAME OF SPOUSE Birth Spouse Employer Bus. Phone Employer Address City/State/Zip Name of parent or guardian if patient is a minor Parent or Guardian Employer Address if different from patient s INSURANCE INFORMATION Dental Insurance Company Mailing Address Name of Subscriber (Self, Spouse or Parent) General Dentist Phone Physician Phone Physician Address Who referred you to our office? ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT* I have received a copy of this office s Notice of Privacy Practices. (Please Print Name) Patient Signature (or Parent/Guardian if minor)

2 I give permission to Trammell Periodontics to disclose and release my protected health information described below to: Name(s): Relationship: Health Information to be disclosed (Check all that apply): My complete dental record (including but not limited to dental/medical history, diagnoses, lab tests, prognosis, treatment and billing, for all conditions). OR My complete health record, as above, with the exception of the following information: This authorization shall be effective until (Check one): All past, present, and future periods or event: unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying Trammell Periodontics, preferably in writing.) (Please Print Name) Patient Signature (or Parent/Guardian if minor)

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4 Trammell Periodontics Medication List If you are taking any prescribed medications, OTC medications, herbal supplements or vitamins, please complete this form. My Name is: My Healthcare Provider s Name is: My Healthcare Provider s Phone Number is: I am currently taking the following: Medication When I take it Dose Other Instructions I have no medications to list at this time.

5 TRAMMELL PERIODONTICS Name: : Dental History 1.When were your teeth last cleaned? By Whom? 2. How Frequently is this usually done? 3. Have you had previous gum trouble (Pyorrhea, trench mouth, etc.) and/or previous gum treatment. If so please specify: 4. Do you see a dentist regularly? How Often? 5. Have you been told what causes dental disease? 6. Do you want to learn how to keep your natural teeth? 7. Have you been shown how to brush your teeth? By whom? 8. How many times a day do you brush your teeth? 9. Type of toothbrush used: Manual Electric Brand used Hard Medium Soft How often replaced? 10. Additional oral hygiene aids used: Tooth picks Dental floss Rubber Tips Water-pik Other 11. Do you use tobacco in any form? 12. How many cigarettes (cigars) do you smoke daily? 13. Have you ever had orthodontic treatment (teeth straightened)? What? 14. Have you had dental X-rays taken in the last year? Yes No 15. Do you think you would be disturbed if you had to lose all of your teeth and wear dentures (false teeth)? 16. Do you have any fear of having dental treatment done? Oral Habits Do you: 1. Press your tongue against your teeth? Yes No 2. Think about the way your teeth fit together?.. Yes No 3. Feel your bite is off?...yes No 4. Clench or grind your teeth? Yes No 5. Awaken in the morning with sore jaws? Yes No 6. Have a popping, clicking, or soreness in the joints just in front of your ears?...yes No 7. Chew on a favorite side? Yes No 8. Bite your lip, cheek, or fingernails? Yes No 9. Hold pens, pencils, or eyeglasses between your teeth? Yes No 10. Bite thread, hold pins, or needles in your mouth?.yes No 11. Awaken in the morning with a dry mouth or generally breathe through your mouth rather than through your nose?..yes Oral symptoms 1. Does food catch or wedge between your teeth? Yes No 2. Do you form tartar rapidly? Yes No 3. Have teeth that are shifting?..yes No 4. Have teeth that are changing colors?.yes No 5. Have sensitive teeth or roots? Yes No 6. Have sore or tender gums? Yes No 7. Bleeding gums?..yes No 8. Gum Abscess? Yes No 9. Loose teeth? Yes No 10. Unpleasant taste? Yes No 11. Unpleasant odor? Yes No 12. Receding Gums?.Yes No 13. Have frequent fever blisters, cold sores, or mouth ulcers? Yes No Comments: No KYLE H. TRAMMELL, D.M.D. DIPLOMATE, AMERICAN ACADEMY OF PERIODONTOLOGY TRAMMELL PERIODONTICS, LLC 1554 E. TRINITY BLVD., MONTGOMERY, AL (334)

6 TRAMMELL PERIODONTICS PATIENT AGREEMENT We are committed to providing you with the best possible care. In order to achieve these goals, we ask for your assistance and understanding of our financial and scheduling policies. Financial Policy Payment for services rendered is due and payable at the time of treatment. We accept Cash, Check, Visa or Mastercard. We have an agreement with CareCredit patient financing, a third party financing company, which may afford you the opportunity to make monthly payments for your treatment. CareCredit offers low interest plans to qualified applicants. Please inquire if you are interested in applying. Minor Children: The parent or guardian that brings a minor child in for treatment in our practice is responsible for payment for services. Administrative Fees and Interest: There is a $30 service charge for returned checks. Account balances that are 30 days or more past due are subject to 1½% monthly interest (18% annual percentage rate (APR)). Past due balances owed are subject to interest and collection practices of this office and to the maximum extent allowable by the State of Alabama. Appointment Policy: We do not double-book appointments in our office, and request 3 business days notice for all cancellations of appointments. Broken appointments or late cancellations of appointments with less than 24 hours notice are subject to a fee of 10% of the total planned appointment cost with a minimum of $50. We ask for your cooperation in managing your appointments so that we can maintain the greatest possible access to care for each of our valued patients. Dental Insurance: Dental insurance amounts are estimated coverage only; the estimated patient share of fees is required at the time of service. The patient/responsible guardian is responsible for amounts not covered by insurance or claims not paid within 60 days from date of service. If you have any questions about the above information or any uncertainty regarding insurance coverage, please don t hesitate to ask us. We are here to help you. Dental Insurance Signature on File: I hereby authorize payment of the insurance benefits otherwise payable to me directly to Trammell Periodontics. Signature Acknowledgement & Agreement to Pay: I have been informed of Trammell Periodontics financial and appointment policies. I agree to be responsible for all fees incurred during the course of my treatment. I understand that the responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees (33.33%), attorney fees and/or court costs, if such be necessary. Signature of Patient or Responsible Party Express prior consent to contact consumer by cell phone. You agree, in order for us to service your account or to collect monies you may owe, Trammell Periodontics, LLC and/or our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or s, using any address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable. I have read this disclosure and agree that Trammell Periodontics, its employees and/or agents may contact me as described above. Signature of Patient or Responsible Party TRAMMELL PERIODONTICS, LLC 1554 E. TRINITY BLVD., MONTGOMERY, AL (334)