Brian H. Jamieson D.D.S. Esthetic Family Dentistry 1533 Grove Street Marysville, WA (360)

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1 Esthetic Family Dentistry 1533 Grove Street Marysville, WA (360) Welcome to Our Office - Tell Us About Yourself Name Last First MI Title Preferred Name: p Male p Female Address: City State ZIP SSN: DOB: Home Phone: Work Phone: Cell Phone: Address: Employer: Occupation: Marital Status: p Single p Married p Divorced p Widowed p Separated p Domestic Partner How did you hear about our office? Do you prefer to be contacted for appointment or confirmation via or phone? (Please circle preference) Insurance Primary Subscriber Name: Relationship to Patient: Subscriber DOB: Subscriber SSN/ID: Subscriber Employer: Insurance Company Name: Insurance Company Address: Insurance Company Phone: Group Number: Insurance Secondary Subscriber Name: Relationship to Patient: Subscriber DOB: Subscriber SSN/ID: Subscriber Employer: Insurance Company Name: Insurance Company Address: Insurance Company Phone: Group Number: Assignment and Release I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Brian H. Jamieson D.D.S. 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 hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature: Relationship: Date: CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. Patient/Guardian Signature: 1 of 3

2 Medical History Do you have a personal physician? p Yes p No Physician s Name: Physician s Phone: Date of last visit: Your current physical health is: p Good p Fair p Poor Are you currently under the care of a physician? p Yes p No Please explain: Do you use tobacco in any form? p Yes p No Have you had any metal rods, pins or implants placed? p Yes p No Are you taking any medications? p Yes p No Please list each one: Have you ever had any surgical procedures? p Yes p No Please list each one: Yes No Conditions Yes No Conditions Yes No Conditions p p Abnormal Bleeding p p Glaucoma p p Sickle Cell Disease p p Alcohol Abuse p p HIV+ AIDS p p Sinus Problems p p Allergies p p Heart Attack p p Stroke p p Anemia p p Heart Murmur p p Thyroid Problems p p Angina Pectoris p p Heart Surgery p p Tuberculosis p p Arthritis p p Hemophilia p p Ulcers p p Artificial Heart Valve p p Hepatitis A p p Asthma p p Hepatitis B Yes No Allergies p p Blood Transfusion p p Hepatitis C p p Aspirin p p Cancer p p High Blood Pressure p p Codeine p p Chemotherapy p p Joint Replacement p p Dental Anesthetics p p Colitis p p Kidney Problems p p Erythromycin p p Congenital Heart Defect p p Liver Disease p p Jewelry p p Diabetes p p Low Blood Pressure p p Latex p p Difficulty Breathing p p Mitral Valve Prolapse p p Metals p p Drug Abuse p p Pace Maker p p Penicillin p p Emphysema p p Psychiatric Problems p p Tetracycline p p Epilepsy p p Radiation Therapy p p Other p p Facial Surgery p p Rheumatic Fever Yes No If Female, Please Answer p p Fainting Spells p p Seizures p p Are you taking Birth p p Fever Blisters p p Sexually Transmitted Disease Control Pills? p p Frequent Headaches p p Shingles p p Are you pregnant? If so, # of Weeks Nearest relative not living with you: p p Are you nursing? Name: Relationship Address: Phone: I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. Signature: Date: 2 of 3

3 DENTAL HISTORY AND CONSENT FOR TREATMENT Reason for seeking dental care at this time: Date of last dental visit: Reason: Date of last X-rays: Former dentist: City/State How often do you: Brush times per Floss times per How do you feel about dental treatment? Relaxed A little uneasy Tense Anxious Very Anxious Do you have or have you ever had any of the following? Please mark boxes and comment. p Aching or sensitive teeth p Broken filling p Areas of food traps p Loose teeth p Unfavorable dental experience p Sensitive or bleeding gums p Difficulty opening wide p Growths or lesions in your mouth p Broken or missing teeth p Bad breath p Clicking or popping jaw p Cold sores p Grinding or clenching p Swollen glands p Jaw pain or tiredness p Dry mouth p Swelling or lumps in mouth p Gum infection p Orthodontic treatment p Gag easily p Other Why did you leave your previous dentist? How can we accommodate you better during your dental visit? If you could change your smile, what would you change? p Remove unsightly fillings p Straighten teeth p Change shape of teeth p Close gaps between teeth p Replace missing teeth p Whitening p Make teeth same color p Other Consent I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor may employ any such assistance as he/she deems appropriate. I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others that may request my records. I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney s and collection fees. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins. Signature of patient or Relationship Date Authorized responsible party 3 of 3

4 1533 Grove Street Marysville, WA (360) Financial Policies and Options We have several financial policy options available for your convenience in receiving the proper dental care. We have found that our patients appreciate knowing exactly what dental financial responsibilities they will incur. Therefore, we inform our patients about our financial policies before we begin treatment. Knowing this ahead of time allows us all to arrange for the completion of the necessary dental treatment. p Dental Insurance Most insurance companies will not cover 100% of all dental expenses. Your portion, not covered by insurance, is due at the time treatment is performed. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. The patient is still the responsible party regarding dental fees. We will be glad to process your insurance forms at no charge. Please be aware that we are only capable of approximating your portion due to the large number of insurance companies and to their periodic changes within their contracts without notifying each dental office of these changes. p Cash or Check Payment in full is due when services are performed. p 5% Prepayment Bookkeeping Courtesy On services over $100, a 5% reduction will be given when paid in full prior to that appointment date. A refund will be made if the proposed treatment is not completed. p Mastercard, VISA, American Express or Discover p Dental Credit Card We ve made arrangements with Care Credit that will finance your dental work with approved credit. No interest payment plans are available. This will allow you to complete your dental work without delay and make relatively small monthly payments. Application forms are available at the reception desk. p Senior Citizen Courtesy For our patients 65 years or older, we offer a 5% fee reduction. On services over $100, an additional 5% reduction will be given if paid prior to your appointment date. p Gradual Treatment Plan If it will be easier financially for those patients without dental insurance, we can plan the completion of your dental work by spreading your appointments over several months or years. We will arrange to do the more urgent services at the beginning of treatment. A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hour notice. Signature: Date:

5 1533 Grove Street Marysville, WA (360) Acknowledgement of Receipt of Statement of Privacy Practices I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Brian Jamieson, DDS. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Brian Jamieson, DDS, reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. ANY MEMBER OF MY IMMEDIATE FAMILY YES NO SPOUSE ONLY YES NO OTHER (PLEASE SPECIFY) YES NO Name of Patient or Personal Representative Signature of Patient or Personal Representative Date Description of Personal Representative s Authority OFFICE USE ONLY BELOW THIS LINE PROVIDED PRIOR TO TREATMENT? DATE PROVIDED: Record of Acknowledgement not obtained YES NO REASON FOR DENIAL: NEEDED MORE TIME TO REVIEW STATEMENT OF PRIVACY PRACTICES. WANTED TO CONSULT WITH ANOTHER PERSON, BEFORE SIGNING UNABLE TO SIGN. REASON NOT GIVEN. OTHER (EXPLAIN):

6 1533 Grove Street Marysville, WA (360) Children s Dental History Patient Is this your child s first visit to the dentist? -If not, how long since the last visit? Were x-rays taken? Has your child had an unfavorable experience in a previous dental (medical) office? Have there been any injuries to the teeth, face, or mouth? -If yes, please explain Why did you bring your child to the dentist today? Has an Orthodontist seen your child? If so, who? Does your child brush daily? p Y p N Floss Daily? p Y p N Does your child receive fluoride vitamins, tablets, water, etc? p Y p N Has your child ever had any pain or tenderness in his/her jaw? (TMJ/TMD) p Y p N Child s Habits Does the child have any of the following habits? Lip Sucking/Biting p Y p N Nail Biting p Y p N Grind Teeth p Y p N Thumb/finger Sucking p Y p N Nursing/Bottle Habits p Y p N Medical History Has the child ever had any of the following conditions? Asthma Y p N p Liver Disorder Y p N p Cancer Y p N p Kidney Disorder Y p N p Hepatitis Y p N p Gastrointestinal Disorder Y p N p Hemophilia/Blood Disorder Y p N p Diabetes Y p N p Rheumatic Fever Y p N p Congenital Heart Defect Y p N p Epilepsy/Convulsions Y p N p Anemia Y p N p Tuberculosis Y p N p ADD/ADHD Y p N p HIV/AIDS Y p N p Pregnancy Y p N p Hearing Impairment Y p N p Disabilities Y p N p Autism Y p N p Latex Allergy Y p N p Please describe any medical problems that your child has: Has your child ever been hospitalized or had surgery? Is the child currently under the care of a physician? p Y p N Is your child currently taking any medications? Please list your child s allergies to any medication or food: Child s Physician Phone I certify that I have read and understand the above information. The above questions have been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my child s health. It is also my responsibility to inform this office of any changes in my child s medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such Dental care to third party payers and/or health practitioners. I also authorize the dental staff to perform the necessary dental service my child may need. Signature X Relationship to Child Date

7 1533 Grove Street Marysville, WA (360) Patient Introduction Children s Form Please assist us by answering all of the following questions. This confidential information is important for our records in evaluating and treating your child. Child s Name Nickname M p F p Child s Birth Date / / Age Child s Home Number Child s Home Address Other family members seen by us Whom may we thank for referring you? Mother s Information Name Stepmother/Guardian Birth Date / / Employer Work # Home # Cell # SS # Father s Information Name Stepfather/Guardian Birth Date / / Employer Work # Home # Cell # SS # Marital Status: Married p Separated p Widowed p Divorced p Single p Primary Dental Insurance Name of Insured/Subscriber Birth Date / / Relationship to patient Insurance Company SS # Employer Insurance Co. Phone # Insurance Company Address Policy ID # / Member ID Group ID # Secondary Dental Insurance (if applicable) Name of Insured/Subscriber Birth Date / / Relationship to patient Insurance Company SS # Employer Insurance Co. Phone # Insurance Company Address Policy ID # / Member ID Group ID # I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY DEPENDENTS. Financial Responsibility - If parents do not live together, the parent that accompanies the child to the appointment will be responsible for payment at each visit. SIGNATURE X Date

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