PAUL T. OLENYN D.D.S.

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PAUL T. OLENYN D.D.S. WWW.SMILESBYDROLENYN.COM 5207 Lyngate Ct Burke, Virginia 22015 PATIENT INFORMATION Tel: 703 978 8560 Date: NEW PATIENT UPDATE Patient: LAST FIRST MI MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT, PLEASE COMPLETE: FULL-TIME PART-TIME PARENT/GUARDIAN NAME(S) SCHOOL/LOCATION Patient Date of Birth: Patient SSN: ADDRESS LINE 1 ADDRESS LINE 2 CITY ST ZIP CODE E-Mail: Referral? Yes No Referred by: Please indicate preferred contact method. HOME: CELL: WORK: EMERGENCY INFORMATION In case of emergency, please provide information for the nearest relative or designated contact person not at the patient s address: Tel #: NAME Employer: ADDRESS LINE 1 ADDRESS LINE 2 RELATIONSHIP EMPLOYMENT INFORMATION Occupation: WORK: DIRECT: OTHER: E-Mail: CITY ST ZIP CODE Subscriber: Subscriber Date of Birth: Subscriber Employer: INSURANCE INFORMATION LAST FIRST MI Subscriber SSN: Patient Relationship to Subscriber: SELF SPOUSE CHILD OTHER PRIMARY INSURANCE CARRIER : Plan name: Group/Policy No.: ID No.: TEL: TOLL-FREE: CITY State Zip Code FAX: Patient Relationship to Subscriber: Self Spouse Child Other SECONDARY INSURANCE CARRIER: Group/Policy No.: ID No.: TEL: TOLL-FREE: CITY State Zip Code FAX: Patient Relationship to Subscriber: Self Spouse Child Other PATIENT REGISTRATION & HISTORY 2015 1/6

Dentist: FORMER DENTIST INFORMATION Telephone: Reason for changing: CITY ST ZIP CODE ORAL HEALTH: EXCELLENT GOOD FAIR POOR Date of Last Dental Visit: DENTAL HISTORY Treatment Type: Y N Burning sensation on the tongue Y N Mouth pain, brushing Y N Chew on one side of the mouth Y N Orthodontic treatment Y N Cigarette, pipe or cigar smoking Y N Pain around the ear Y N Clicking or popping jaw Y N Periodontal treatment Y N Dry Mouth Y N Sensitivity to cold Y N Fingernail biting Y N Sensitivity to Heat Y N Food collection between teeth Y N Sensitivity to sweets Y N Foreign objects Y N Sensitivity when biting Y N Grinding teeth Y N Sores or growths in your mouth Y N Gums swollen or tender How often do you floss? Y N Jaw pain or tiredness Y N Lip or cheek biting How often do you brush? Y N Loose teeth or broken fillings Y N Mouth Breathing CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS: Y N Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.) Y N Any unusual speech habits? If yes, explain: Y N Any lost teeth? If yes, list: Y N Does the patient receive assistance with brushing and flossing? If yes, how often? Physician: Telephone: PRIMARY PHYSICIAN INFORMATION Pharmacy Name: Telephone: PHARMACY INFORMATION PATIENT REGISTRATION & HISTORY 2015 2/6

GENERAL HEALTH: EXCELLENT GOOD FAIR POOR MEDICAL HISTORY Y N Under a physician s care now? Y N Any hospitalization in the past 5 years? Describe: Y N Any serious illnesses/surgeries? Describe: Y N Use tobacco in any form? If Yes, Type: Y N Is pre-medication required before dental visits due to heart condition or artificial joint? Y N Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section. FEMALE PATIENTS: Y N Currently nursing? Y N Currently pregnant? Due Date: ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): ACID REFLUX CORTISONE MEDICINE OSTEOPOROSIS ADHD COUGH, PERSISTENT OR BLOODY PACEMAKER NONE AIDS/HIV DEPRESSION PAIN IN JAW JOINTS ALZHEIMER S DIABETES PSYCHIATRIC TREATMENT ANAPHYLAXIS DIZZINESS/FAINTING RADIATION ANGINA EMPHYSEMA RENAL DIALYSIS ANEMIA EPILEPSY/SEIZURES RESPIRATORY DISEASE ANOREXIA FREQUENT EAR INFECTIONS RHEUMATIC FEVER ANXIETY FREQUENT HEADACHES SEASONAL ALLERGIES ARTIFICIAL HEART VALVE GLAUCOMA SHINGLES ARTHRITIS HEARING PROBLEMS SINUS PROBLEMS ASTHMA HEART ATTACK STROKE AUTISM/ASPERGER S HEART DISEASE SWOLLEN FEET OR ANKLES BLEEDING DISORDER HEART MURMUR SWOLLEN NECK GLANDS BREATHING PROBLEMS HEPATITIS THYROID CONDITION BULIMIA HERPES TONSILLITIS CANCER HIGH/LOW BLOOD PRESSURE TUBERCULOSIS CEREBRAL PALSY HIGH CHOLESTEROL TUMORS CHEMOTHERAPY HIVES/ RASH ULCERS CHEST PAINS HYPOGLYCEMIA VENEREAL DISEASE CHEMICAL DEPENDENCY JOINT REPLACEMENT YELLOW JAUNDICE CHICKEN POX COLD SORES CIRCULATORY PROBLEMS CONGENITAL HEART LESIONS CONVULSIONS KIDNEY DISEASE LEUKEMIA LIVER PROBLEMS MITRAL VALVE PROLAPSE MONONUCLEOSIS ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY.) ASPIRIN CODEINE PENICILLIN NONE ANESTHETIC LOCAL LATEX SULFA DRUGS BARBITURATES NITROUS OXIDE SEDATION OTHER ANTIBIOTICS Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients? Y N If yes, please describe: Is there anything important about your medical condition we have not asked? Y N If yes, please describe: PATIENT REGISTRATION & HISTORY 2015 3/6

MEDICATION INFORMATION ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): ANTIBIOTICS/SULFA DRUGS INSULIN OTHER (PLEASE LIST ) ANTIHISTAMINES/ALLERGY NITROGLYCERIN ASPIRIN ( DAILY) ORAL CONTRACEPTIVES BLOOD THINNERS OSTEOPOROSIS MEDICATIONS BLOOD PRESSURE MEDICATION CANCER/CHEMO MEDICATIONS CORTISONE/STEROIDS HEART MEDICATION OTHER DIABETIC MEDICATIONS RECREATIONAL DRUGS THYROID MEDICATIONS TRANQUILIZERS NONE DRUG NAME DOSAGE REASON PRESCRIBED PATIENT REGISTRATION & HISTORY 2015 4/6

Financial Guidelines We are committed to providing you with the best care possible to achieve total oral health. In order to achieve these goals, we need your assistance and your understanding of our financial guidelines. Insurance We accept all major dental insurance payments, however we may not be an in network provider for your plan. If we are not an in network provider, review your plan details, as in many cases insurance reimbursement is very similar. - We are in network for Delta Dental Premier, Aetna, Metlife, Blue Cross/Blue Shield and United Concordia. We do not participate in any HMO/DMO plans. - No estimate is a guarantee of payment. Please understand, you are responsible for all charges not paid by your insurance. Also, many insurance companies are excluding certain dental procedures or downgrading procedures to a lesser reimbursement level; in which case, you would be responsible for the difference. - Workers Compensation claims will be filed for you. Please understand the carrier will assign a dollar amount that will be paid towards the claim, which may or may not cover the entire fee. Any amount not covered by the carrier, will be your responsibility. - Minors must be accompanied by a parent or legal guardian. If the parents are separated or divorced, the person accompanying the minor will be responsible for copayment at the time of service. Payments - Patient portion or patient co-pay is due at the time services are rendered - unless prior financial arrangements have been made. - Payment Information: o All major credit cards are accepted (Visa, MasterCard, Discover) o Various financing options with CareCredit - Balances left over 90 days will incur an 18% or $10 minimum monthly finance charge. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Short Cancelled/ Missed Appointments - Please give 48 hours notice if you are unable to keep your reserved time. Unless an emergency occurs, we expect to run on time for your appointments, and we appreciate the same courtesy from you. - Short canceled or missed appointments: There will be a charge of $50 for a standard missed appointment when there was no prior notification. Please note if you missed an appointment for a major restorative appointment, you may be charged a higher fee. By signing below I acknowledge I have read and understand the guidelines above. Signature: Date: PATIENT REGISTRATION & HISTORY 2015 5/6

PATIENT CONSENT- PAYMENT AUTHORIZATION SIGNATURE ON FILE To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status of if my medication changes, I shall inform the dentist and staff at the next appointment without fail. I hereby authorize payment directly to Dr. Olenyn of the dental benefits otherwise payable to me. I hereby authorize Dr. Olenyn to release any information concerning my health or dental care, advice, treatment or supplies provided. This information is to be used in administering dental claims and/or discussing treatment options with other dental professionals. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered. By signing below, I acknowledge that I have read and understand the statements above. Signature: Date: PATIENT REGISTRATION & HISTORY 2015 6/6

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