MEDICAL HISTORY. PATIENT S NAME Last First Initial Date of Birth CIRCLE THE APPROPRIATE ANSWER COMMENTS MED. ALERT ANEST. 1.

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2 PATIENT S NAME Last First Initial Date of Birth CIRCLE THE APPROPRIATE ANSWER 1. Physician s Name COMMENTS Address 2. Are you under a physician s care?...yes NO Since when Why? 3. When was your last complete physical exam? 4. Are you taking any medications, vitamins or supplements?...yes NO _ 5. Are you allergic to any medications or substances?...yes NO _ 6. Do you have any other allergies?...yes NO _ 7. Do you have any sensitivities to penicillin, antibiotics, anesthetics or other medications?...yes NO _ 8. Are you sensitive to any metals or latex?...yes NO 9. Are you pregnant or suspect you may be...yes NO If so how many weeks? 10. What type of birth control do you use? Please list 11. Have you ever been treated for or been told you have heart disease?...yes NO 12. Do you have a pacemaker or an artificial heart valve implant?...yes NO 13. Do you have high or low blood pressure?...yes NO If so which and list medications 14. Have you ever had a serious illness or major surgery?...yes NO If so list date and type 15. Have you ever had radiation or chemotherapy treatment?...yes NO If so list date and type 16. Do you have arthritis?...yes NO If so list type and medications 17. Do you have any artificial joints / prosthesis?...yes NO If so list date and type 18. Do you have any blood disorders, such as anemia, leukemia, etc?...yes NO 19. Do you have any stomach problems?...yes NO If so list 20. Do you have any kidney problems?...yes NO 21. Do you have any liver problems?...yes NO 22. Are you diabetic?...yes NO If so list type 23. Do you have asthma?... YES NO If so list medications 24. Do you have epilepsy or seizure disorders?... YES NO If so list type and medications 25. Do you have or have had a sexually transmitted disease?...yes NO 26. Have you tested HIV positive?...yes NO If so when 27. Do you have any infectious diseases?...yes NO 28. Have you had or tested positive for hepatitis?...yes NO If so list type and when 29. Do you or have you had T.B.?...YES NO 30. Do you smoke tobacco?...yes NO How much? For how long? 31. Do you chew tobacco?...yes NO List type How much? For how long? 32. Do you consume alcoholic beverages?...yes NO If so how much? Daily Weekly 33. Do you use controlled substances?...yes NO If so list type and frequency 34. Have you had psychiatric treatment?...yes NO If so list type and medications 35. Do you take medications for osteoporosis or osteopenia?...yes NO I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE PATIENT S SIGNATURE DATE DENTIST S SIGNATURE DATE ANEST. MED. ALERT MEDICAL HISTORY

3 PATIENT S NAME Last First 1. Purpose of initial visit Initial Date of Birth COMMENTS 2. Are you aware of a problem? 3. How long since your last dental visit? 4. What was done at that time? 5. Previous dentist s name Address: Tel. ( ) 6. When was the last time your teeth were cleaned? CIRCLE THE APPROPRIATE ANSWER 7. Have you made regular visits?... YES NO How often? 8. Were dental x-rays taken?... YES NO 9. Have any teeth been removed?... YES NO Why? 10. Have they been replaced?... YES NO 11. How have they been replaced? a. Fixed bridge Age b. Removable bridge Age c. Denture Age 12. Are you happy with the replacement?... YES NO If no, explain 13. Would you like to know about permanent replacements?... YES NO 14. Have you ever had any problems or complications with previous dental treatment? YES NO If yes, explain 15. Do you clench or grind your teeth?... YES NO 16. Does your jaw click or pop?... YES NO 17. Have you experienced any pain or soreness in the muscles or your face or around your ear?... YES NO 18. Do you have frequent headaches, neckaches or shoulder aches?... YES NO 19. Does food get caught between your teeth?... YES NO 20. Are any of your teeth sensitive to hot cold sweets pressure 21. Do your gums bleed or hurt?... YES NO When? 22. How often do you brush your teeth? When 23. Do you use dental floss? YES NO How often? 24. Are any of your teeth loose, tipped or shifted?... YES NO 25. Are you happy with the appearance of your teeth?... YES NO 26. How do you feel about your teeth in general? 27. Do you feel your breath is offensive at times?... YES NO 28. Have you ever had gum treatment or surgery?... YES NO What Where When 29. Have you had any orthodontic work?... YES NO 30. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike? 31. Do you have any questions or concerns?... YES NO I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE. PATIENT S SIGNITURE DATE DENTIST S SIGNITURE DATE ANEST. MED. ALERT DENTAL HISTORY

4 Moreno Dental Dr Ronald Moreno, Dr John Young 3115 Howe Pl Ste 101, Bellingham, WA FINANCIAL POLICY Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. The following is a statement of our financial policy, which we require you read, agree to and sign prior to any treatment. *All patients must complete our patient information forms before seeing the doctor. *Full payment of the portion not covered by the insurance co. is due at time of service. *We accept cash, check, Debit,Visa/MasterCard, Discover Card or American Express. *Additionally, we offer the option of Chase Financial, and Care Credit allowing the patient to have small payments over a period of time, in some cases 6,12,18 and 24 months same as cash with no interest charge. We confirm your appointment with a courtesy call, but you are responsible to keep your appointment or give our office notice. In some cases you might be asked to pay a deposit before your appointments for larger treatments. Initial INSURANCE We are happy to submit your insurance claims if you provide all the necessary information. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. Our practice is committed to providing the best treatment possible for our patients and we charge what is usual and customary for our area. You are responsible for paying the bill in full regardless of the insurance company s determination. We do our best to estimate your balance owing before insurance pays, please remember this is only an estimate and not a guarantee. If you elect to have tooth colored filling on back teeth you might incur more out of pocket expense after your insurance pays. Occasonally, insurance companies are slow to pay claims, to avoid interest charges from our office, you may want to pay the balance owing and receive a refund after the insurance company pays. We are no longer accepting patients receiving DSHS medical assistance. I am not receiving DSHS medical assistance and I agree to pay for services. If I become eligible for DSHS medical assistance for the a date of service, I agree to inform you before treatment is rendered. Initial DELINQUENT ACCOUNTS We charge 1.5% interest after 60 days 18% apr. We also refer delinquent past due accounts to an outside collection agency. An account that is referred to a collection agency will result in termination of dental services from our office. We will be available for 30 days after the account is transferred to the collection agency for emergency care only. This is to allow the patient to find other dental care. Initial MISSED APPOINTMENTS We require 24 hours notice for any appointment change but would appreciate 48 hour notice. After a missed appointment there may be a $45.00 fee charged to your account if the time scheduled for your appointment is an hour or longer, then the charge would be for each hour. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read, understand and agree to the above Financial Policy Patient or Responsible Party Date

5 PRIVACY POLICY The privacy of your health and financial information is very important to our office. Federal and state law requires us to maintain the privacy of your health information. That law also requires us to give you this notice about our privacy practices, our duties, and your rights concerning your health information. This law takes effect April 14, 2003, and our notice will remain in effect until the guidelines change. We reserve the right to change our Privacy Policy and terms of this notice at any time provided such applicable law permits the change. We reserve the right to make the changes in our privacy practices and the new terms of our Policy effective for all health information that we maintain, including health information that we created or received before we made the changes. When we make a significant change in our Privacy Policy, we will make the new Policy available on request and post the new Policy. Treatment: We may use your health information for treatment or disclose it to a dentist, physician or other health care provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. On Your Authorization: You may give us written authorization to use your health information or to disclose it to any one for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect. Handling of our Charts: The outside of our chart will list only the patient s first and last name. Charts are stored behind the reception desk. When they are in use they will be placed in such a way so the names are not visible. After treatment, they are placed in a file on the reception desk or in Dr. Moreno s office. Only staff members or Dr. Moreno or Dr Young will retrieve or file charts. If we receive a request for release or duplication of records, that must be accompanied by a signed release form. If a chart needs to be inactivated the information is stored in a secure off-site facility. Schedules: Daily schedules that are placed in treatment areas out of sight by patients. The schedules are in our computer system, which requires passwords. Shredder: Any papers with a patient s personal or financial information, that needs to be discarded will be shredded. Computer Screens: Computer screens will be placed so that they are discreetly away from general view. Conversations: Financial arrangements, health details, treatment plans, referral and other information will be discussed as privately as possible. Health issues will be discussed in the treatment areas by the Doctor and auxiliaries as needed. Health issues that require identifying stickers, will be placed inside the chart. Treatment of everyday papers: Referrals from other professionals are reviewed in Dr. Moreno or Dr.Youngs s private office and then filed in the dental record. Insurance forms will be sent electronically when possible otherwise they are mailed to the insurance company. X-rays sent to our office are stored in the patient s chart or in a file maintained by the receptionist. Correspondence from other offices will be reviewed in private then filed. Images and correspondence sent by and to our office by are sent and received in the Office Mangers office. This office is in a secure and private location. Back-up Devices: While they are in the office they are in a secure location. When they are out of the office they are secured at the home of the HIPPA officer or their representative.

6 Appointment confirmation: We may use or disclose your health information to provide you with appointment confirmations or appointment changes. We may use message given to an individual, voice mail, answering machines, postcards, letters or . Access: You have the right to look at or obtain copies of your health information. The request must be in writing and subject to a fee. Disclosure Accounting: You have the right to receive a list of insurances companies, in which we or our business associates, disclosed your health information to for over the last 6 years (but not before April ). Restriction: You have the right to request that we place additional restrictions on our use of disclosure of health information. We are not required to agree to these restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing and signed by a person authorized to make such an agreement. Confidentiality Agreements: All employees have signed a confidentiality agreement. As well, as outside vendors, such as our software and support computer companies, collection agencies, and maintenance contractors. If you have any questions or special requests please inform someone on our office staff and they can make the HIPPA Officer available to you. Thank you for your time and consideration in regards to this matter. Moreno Dental-Ronald A Moreno DDS PS and John D Young DDS Hay copias de este documento en Espanol si lo desea

7 Consent for Use and Disclosure of Health Information Notice of Privacy Practices: You have the right to read our Privacy Policy before signing this consent. Our Policy provides a description of our treatment and payment practices and healthcare operations. It explains the procedures we use to protect your healthcare and personal information. A full copy of our Privacy Policy accompanies this consent, please read it carefully and completely. We reserve the right to revise our Privacy Policy and will have the most current copy available on request as well as posted in our reception room. You have the right to revoke thisc onsent by contacting our HIPP A representative. If you choose to not sign this consent, we have the right to decline treatment. Purpose of Consent: By signing this form, you will consent to Moreno Dental, Dr. Moreno and Dr. Young and staff, the use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. I, have had full opportunity to read and consider the contents of this Consent form and your Privacy Policy. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operation. I give my permission to share my personal information with: Signature Date If this consent is signed by a personal representative on be half of the patient complete the following: Personal Representative's Name: Relationship to patient:

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