RIVERTOWN DENTAL CENTER

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1 PATIENT INFORMATION RIVERTOWN DENTAL CENTER DATE PATIENT NAME DATE OF BIRTH S.S.N AGE SEX M F MARRIED SINGLE SEPARATED DIVORCED WIDOWED SPOUSE S NAME ADDRESS CITY ZIP PHONE ( ) CELL PHONE ( ) DENTAL INSURANCE WHO IS RESPOSILE FOR THIS ACCOUNT? INSURANCE COMPANY ASSIGNMENT AND RELEASE I certify that I, and /or my dependent(s), have insurance coverage with and assign directly to Rivertown Dental Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions Rivertown Dental Center may use my health care information and may disclose such information to the abovenamed Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian, Or Personal representative: Printed Name of Patient, Parent, Guardian, or Personal Representative: Date: Relationship to patient: IN CASE OF EMERGENCY IN CASE OF AN EMERGENCY, CONTACT (Specify someone who does not live in your household.) Name: Relationship: Home Phone: ( ) Work Phone:( )

2 HEALTH HISTORY Place a mark on Yes or No to indicate if you have had any of the following: AIDS/HIV EPILEPSY ANEMIA FAINTING OR DIZZINESS ARTHRITIS/RHEUMATISM GLAUCOMA ARTIFICIAL HEART HEADACHES VALVES ARTIFICIAL JOINTS HEART MURMUR ASTHMA HEART PROBLEMS BACK PROBLEMS HEPATITIS TYPE BLEEDING ABNORMALLY HERPES BLOOD DISEASE HIGH BLOOD PRESSURE CANCER JAUNDICE CHEMOTHERAPY JAW PAIN CIRCULATORY KIDNEY DISEASE PROBLEMS CONGENITAL HEART LESIONS LIVER DISEASE CORTISONE LOW BLOOD PRESSURE TREATMENTS COUGH, PERSISTENT OR MITRAL VALVE BLOODY PROLAPSE DIABETES NERVOUS PROBLEMS EMPHYSEMA PACEMAKER RADIATION TREATMENT PSYCHIATRIC CARE RESPIRATORY DISEASE CONTACT LENSES SCARLET FEVER RHEUMATIC FEVER SINUS TROUBLE SHORTNESS OF BREATH SPECIAL DIET SKIN RASH SWOLLEN FEET OR STROKE ANKLES THYROID PROBLEMS SWOLLEN NECK GLANDS TUBERCULOSIS TONSILITIS ULCER TUMOR OR GROWTH ON HEAD OR NECK UNEXPLAINED WEIGHT STD/ VENEREAL DISEASE LOSS Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include combinations of Ionimin, Fastin (brand names of phentermine), Pondimin and Redux (dexferfluramine). Yes No How many times in the past year have you used a recreational drug or used a prescription medication for nonmedical reasons? NONE 1 or MORE Women: Are you pregnant? Due Date Nursing Taking Birth Control?

3 PHARMACY NAME PHONE List any medications you are currently taking: ALLERGIES (CIRCLE): ASPIRIN BARBITURATES CODEINE IODINE LATEX LOCAL ANESTHETIC PENICILLIN SULFA OTHER DENTAL HISTORY Place a mark of Yes or No to indicate if you have had any of the following: Bad Breath Tobacco Use Bleeding Gums Mouth Breathing Blisters On Lips Or Mouth Mouth Pain When Brushing Burning Sensation On Tongue Orthodontic Treatment Clicking or Popping Jaw Pain Around Ear Dry Mouth Periodontal Treatment Fingernail Biting Sensitivity to Cold Food Collecting Between Teeth Sensitivity to Heat Grinding Teeth Sensitivity to Sweets Gums Swollen or Tender Sensitivity when Biting Jaw Pain or Tiredness Sores or Growths in your Mouth Lip or Cheek Biting Loose Teeth or Broken Fillings How often do you brush? How often do you floss? When was your last visit to the Dentist? Patient Consent - HIPPA I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:! Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly and indirectly.! Obtain payment from third party payers.! Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed and given the right to review the contents of your Notice of Privacy Practices, which contains a more complete description of the users and disclosers of my health information, prior to signing this consent. I understand that this organization has a right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I am aware that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. If the office does agree with my request, I am aware they are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time. Except to the extent that the office has taken action relying on this consent. Patient Name: Date: Relationship to Patient (if minor): Signature:

4

5 CONSENT TO PERFORM DENTISTRY I hereby authorize and direct the dentist(s) of the Rivertown Dental Center to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs, or diagnostic aids:! Consult with examination for future treatment.! Preventive hygiene treatment (prophylaxis), and the application of topical fluoride.! Application of plastic sealants to the grooves of the teeth.! Treatment of diseased or injured teeth with dental restorations (fillings and crowns).! Replacement of missing teeth with dental prostheses (i.e. bridges, partials, and full dentures).! Removal (extraction) of one or more teeth! Treatment of diseased or injured oral tissue (hand and/or soft).! Treatment of malposed (crooked) teeth and/or oral development of growth abnormalities. I understand that there are risks involved in this treatment, and hereby acknowledge that these risks will be explained to me. I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same. I will be advised that the success of the dental treatment to be provided will require that the patient and/or parents of the patient to follow post-care instructions of the dentist(s). I agree that the success of the treatment requires that all post-operative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his/her auxiliaries must be maintained. I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I, therefore, authorize and request the performances of any additional procedures that are deemed necessary for desirable oral health and well being, in the professional judgment of the dentist. There are possible risks and complications associated with the administration of local anesthesia, sedation, and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip or cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping or breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications. I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor(s). Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nose piece leaves an indention or ring around the nose, which disappears shortly after procedure. I understand and have been informed of the above risks and complications. I also authorize the doctor(s) to use photographs, radiographs, other diagnostic materials and treatment records for the purposed of teaching, research, and scientific publications. I hereby state that I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner; and I understand that I have the right to be provided an answer to the questions which may arise during and after the course of my treatment. I further understand that this consent will remain in effect until such time that I choose to terminate it. Patient s Name: Name of Parent or Guardian (minors only): Signature of Patient or Parent/Guardian: Date:

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