TIME 10:24 AM

PATIENT REGISTRATION

DATE 11/13/2014

Patient Information

Additional Comments:Referred By:

Previous Dentist:

Emergency Contact:

Emergency Contact #:

Primary Insurance Information

Responsible Party (if someone other than the patient)

ID:

First Name:

Policy HolderResponsible Party

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Section 2

Full Time Part Time Retired

Section 3

Address 2:

State / Zip:

Sex: Marital Status: Married Single Divorced Separated Widowed

E-mail: I would like to receive correspondences via e-mail.

Address:

City:

MaleOther

Female

Birth Date:

Full Time Part Time

Employment Status:

Student Status:

Medicaid ID: Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg.:

Name of Insured: Self Spouse Child Other

First Name:

Address 2:

First Name:

Address:

Home Phone:

Birth Date: Drivers Lic:Soc Sec:

Work Phone: Ext: Cellular:

City, State, Zip: Pager:

Last Name: Middle Initial:Last Name:

Insured Soc. Sec: Insured Birth Date:

Secondary Insurance Information

Name of Insured: Self Spouse Child Other

Rem. Deduct: .00

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00 Rem. Deduct: .00

Soc. Sec:Age: Drivers Lic:

Chart ID:

Home Phone: Work Phone:

Pager:

Ext: Cellular:

Last Name: Middle Initial:

Patient Is:

Relationship to Insured:

Relationship to Insured:

Preferred Name:

TIME 7:37 AM DATE 11/5/2013

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date _____________________________________

Weddington Family Dentistry

Do you have, or have you had, any of the following?

Yes No

Are you allergic to any of the following?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may

following questions.have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

If yes, please explain:Are you under a physician's care now? Yes No

Have you ever had a serious head or neck injury?Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Yes No If yes, please explain:Yes No If yes, please explain:Yes No If yes, please explain:

Comments:

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions

HerpesAnemiaAngina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

RheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStroke

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Rheumatic FeverRenal Dialysis

Radiation TreatmentsRecent Weight Loss

Yes NoYes NoYes No

Hepatitis B or C

High Blood Pressure

Yes NoYes NoYes NoYes No

HemophiliaHepatitis A

Pain in Jaw JointsParathyroid DiseasePsychiatric Care

Yes NoYes NoYes No

Hives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve Prolapse

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Swelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Other

Aspirin

If yes, please explain:

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you

Are you on a special diet? Yes NoDo you use tobacco? Yes No

Do you use controlled substances? Yes No

Yes No

Have you ever been hospitalized or had a major operation?

Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? Yes No

Yes No

Metal Latex Sulfa drugsPenicillin Codeine Local Anesthetics Acrylic

High Cholesterol

Osteoporosis Yes No

HIPAA Acknowledgment & Authorization to Release

Patient Name:_____________________________________________ Weddington Family Dentistry is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient’s instructions. I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. I, ___________________________________________________ acknowledge that I have reviewed and received a copy of this office’s Notice of Privacy Practices explaining: • How this office will use and disclose my protected health information • My privacy rights with regard to my protected health information • This office’s obligations concerning the use and disclosure of my protected health information I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revision upon request. I also understand that if I have any questions or complaints, I may contact Weddington Family Dentistry. You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services. Signature:_________________________________________Date:________________________ Name (Print): _________________________________________ Relationship to Patient:______________________ Office Use Only We were unable to obtain a signed acknowledgment for the following reasons: �Patient refused to sign. Date:____________________________ �An emergency situation prevented us from obtaining an acknowledgement �Communication barriers prohibited obtaining an acknowledgment �Other:_______________________________________________ Attempt made by:______________________________________ Date:______________

Entity to Receive Information Description of Information to be released* Check each person/entity that you Check each that can be given to person/entity approve to receive information on the left in the same section �Voice Mail �Results of lab tests/x-rays �Other: __________________________________ �Spouse (Provide Name & Phone Number) �Financial �Medical �Treatment ______________________________________________ �Parent (Provide Name & Phone Number) �Financial �Medical �Treatment ______________________________________________

Weddington Family Dentistry • 3099 Rock Hill Church Road Concord, NC 28027 • Phone: (704) 782-2630

FINANCIAL & INSURANCE POLICIES We are committed to providing you with the highest quality of dental care using only the best materials and education available. In doing so, we have formulated the following policies to help keep the cost of dentistry down, and to continue to provide quality care to our valued patients.

Payment in full is due before services are provided. Our office accepts cash, personal checks, MasterCard, Visa, Discover, and Care Credit. We will still estimate and bill out to insurance, but the remaining balance is due the same day that treatment is given.

If you have dental insurance, we will help you process your insurance claims. Please remember however, that you are responsible for the portion of your treatment not covered by insurance. We must also emphasize that as your dental care provider, our relationship is with you – our patient, not with your insurance company. Your insurance plan is a contract between you, your employer, and the insurance company.

Once your claim pays, you might have either a credit or a balance. When this occurs we will use your credit card on file to refund or charge your account balance to zero.

Returned checks and balances older than 60 days will be subject to administrative fees and finance charges. Accounts submitted to court will be charged a $50 administrative fee. Additionally, charges of $50 will be incurred for broken appointments and appointments cancelled without 48-hour advanced notice.

If you have any questions or concerns about our policies, please feel free to ask the receptionist or manager on duty.

Patient Name: __________________________________ Today’s Date: ____________ Patient Signature:_______________________________________________________________

Weddington Family Dentistry • 3099 Rock Hill Church Road Concord, NC 28027 • Phone: (704) 782-2630

I, ___________________, hereby authorize and request the release of X-rays of: Patient’s Name: ___________________________________________________ Date of Birth: _____________________________________________________ From: ___________________________________________________________ ________________________________________________________________________________________________________________________________ Please send the x-ray to: Weddington Family Dentistry 3099 Rock Hill Church Rd. Concord, NC 28027 weddingtonfamilydentistry@yahoo.com (email preferred) 704-782-2630- Phone 704-782-2005- Fax Patient’s Signature:__________________________________________ Date: _____________________________________________________