Dr. Lisa J. McDonald Welcome to our Practice!

PATIENT HEALTH RECORD

Date:

Dr. Mr. Mrs. Ms. (Last)

(First) (Initial)

I prefer to be addressed as:

Address: (Street) (City)

(State)

(Zip code)

Home Phone: Business Phone:

Cell Phone: E-Mail address:

Date of Birth: Sex: M F Married: Single: Other: Spouse's Name:

Employer: Social Security #:

Emergency Contact — Name: Phone Number:

Whom may we thank for referring you to us:

MEDICAL HEALTH

What is your general state of health? Excellent Good Fair Poor

Name/Address/Phone # of Physician:

Have you been under a physician's care during the last two years?

Have you been treated in a hospital in the past three years?

Have you had major surgery?

History with general or IV anesthesia?

If female: Are you pregnant or nursing?

Do you or have you had any of the following?

Past Present None

Blood

Past Present None

Pressure (office to take)

Past Present None

Epilepsy or Seizures [ ] [ 1 [ 1 Kidney Problems [ 1 [ ] [ 1 Cancer [ 1 [ 1 [ 1 Fainting or Dizziness [ 1 [ ] [ ] Bruise/Bleeds easily [ 1 [ l [ 1 Chemotherapy E 1 [ 1 [ 1 Stroke [ 1 [ 1 [ l Heart Problems [ ] [ 1 [ 1 Radiation Therapy [ 1 [ 1 [ 1 Persistent Cough [ 1 [ 1 [ 1 Chest Pain/Angina [ 1 [ 1 [ 1 Thyroid Disease [ 1 [ l [ 1 Emphysema/Bronchitis [ ] [ 1 [ 1 Osteoporosis/Penia [ 1 [ ] [ 1 AIDS/HIV+ [ 1 [ ] [ 1 Tuberculosis/PPD+ [ 1 [ ] [ ] Rheumatic Fever [ 1 [ ] [ 1 Arthritis [ 1 [ 1 [ 1 Asthma [ 1 [ 1 [ ] Heart Murmur [ ] [ 1 [ ] Fibromyalgia [ 1 [ ] [ 1 Sinus Problems [ 1 [ 1 [ 1 Mitral Valve Prolapse [ 1 [ 1 [ ] High Blood Pressure [ ] [ ] [ 1 Anemia/Sickle Cell [ l [ 1 [ 1 Congenital Heart Lesions [ 1 [ 1 [ 1 Gastric Reflux [ ] [ 1 [ 1 Hepatitis A, B, C [ ] [ 1 [ 1 Heart Surgery [ 1 [ 1 [ 1 Heart Burn [ ] [ 1 [ 1 Liver Disease [ 1 [ 1 [ 1 Artificial Heart Valves [ 1 [ ] [ 1 Snoring [ 1 [ 1 [ 1 Pneumonia [ 1 [ ] [ 1 Pacemaker [ ] [ 1 [ 1 Sleep Apnea [ 1 [ 1 [ 1 Nervousness/Anxious [ 1 [ 1 [ 1 Dry Mouth [ ] [ 1 [ 1 Daytime Sleepiness [ 1 [ 1 [ ] Irregular Heart Beat [ 1 [ 1 [ 1 Latex Allergy [ 1 [ 1 [ ] Diabetes [ 1 [ l [ 1 Blood Thinners [ 1 [ 1 [ 1 Artificial Joints [ 1 [ 1 [ 1 Herpes [ 1 [ 1 [ 1

Do you have any condition, disease or problem not previously listed?

Please list all the medications you are taking, including over the counter drugs and herbs.

Medications: Dosage/Day Reason Vitamins & Supplements Yes No

If yes, do you take daily:

Mulitvitamin Yes No

Fish Oil (Omega 3) Yes No

Joint Support Yes No

Other:

Are you allergic to: [ ] Penicillin [ ] Codeine [ ] Local Anesthetics [ ] Other

Do you take medicine for osteoporosis? Yes No

DENTAL HEALTH

When was your last dental visit? How often did you see your dentist?

Are you having any dental problems that require immediate attention?

Do you have frequent headaches? Ear aches? How often?

Is there anything that will cause your jaw muscles to be tired or sore or cause headaches?

Are your jaw joints painful or tender? If yes, please describe

Have you had trauma to your jaw? Do your jaw joints pop or click or grate?

Do your jaws ever feel tired or ache? Have you ever been told you have TMJ?

Do you clench or grind your teeth?

Does your bite feel comfortable? Have you noticed any change in your bite?

Have you ever been told you have periodontal disease? Have you ever had periodontal treatment?

Do your gums bleed while cleaning? Do your gums ever feel tender or swollen?

How often do you brush your teeth? Floss? Water Jet?

Do any of the following cause tooth discomfort? Hot Cold Sweets Chewing

Have you noticed any changes in your teeth?

Do you have loose teeth? Worn teeth? Broken or chipped teeth? Food Traps?

Can you chew on both sides of your mouth? Comfortably?

Do you lose fillings or break fillings? Do you usually have cavities?

Have you ever had orthodontic treatment? When?

Do you have any missing teeth? Have they been replaced?

Do you have a Fixed bridge? Removable partial? Full dentures? Dental Implants?

Are you comfortable with the replacement? Please describe:

How do you feel about the appearance of your smile?

What improvements would you like to make in your mouth?

Please add anything you feel is important:

To the best of my knowledge, all of the preceding is correct. If I ever have a change in my health, medication, or medical condition, I

will inform the dentist at my next appointment. I authorize release of any information to my insurance company and/or other

healthcare providers involved in my treatment.

Signature Date

Doctor Signature Date

PERSONAL DENTAL NEEDS SURVEY

Name:

Please rate on a scale of 1-5 the importance of each of the following regarding your dental care. (The most important

would be #1.)

Preventive Dental Health care

Excellence and Quality of service

Other

Freedom from pain

Cost and affordability

Please rate, as above, what a dentist has to do to gain your confidence.

Show me what he/she is doing or needs to do so I can clearly understand what is happening.

Listen to my concerns and explain thoroughly the procedures to be performed.

Make sure I feel comfortable and informed at all times.

Please circle the level of fear you have about your dental visits. (10 being the greatest fear.)

1 2 3 4 5 6 7 8 9 10

I would like to know about these options available to me for maximizing my comfort and my experience during my

visit. (Check all that apply.)

Music and earphones (Please list the type of music)

Sedative medications

Patient education materials

Are you concerned about the following? (Yes or No):

Existing discomfort?

Replacing old silver fillings?

Recurring or untreated gum disease?

Mouth odor?

Whitening your teeth?

Appearance of my smile?

Prevention of decay?

Other

PLEASE CIRCLE ONE:

When discussing my treatment plan, I prefer:

THE BIG PICTURE DETAIL BY DETAIL

When evaluating my smile, it's most important:

WHAT I SEE WHAT OTHERS SEE

HIPAA CONSENT

By signing this form, you consent to our use and disclosure of your protected health information which may include

e-mailing documents to specialists to carry out treatment, payment activities and health care operations. It also

confirms that you have read and been offered a copy of our Notice of Privacy Practices.

Signature Date

INSURANCE AND BILLING INFORMATION

Person Responsible for Account

[ ] Self (skip this section) [ ] Other (please complete the following)

Relationship to the Patient: Work # ( )

Name: Home # ( )

Address: Other # ( )

Employer: Birthdate: Age: Gender: M F

Occupation: Marital Status: (Spouse's Name: )

Social Security Number:

IF YOU HAVE DENTAL INSURANCE

If you have dental insurance, we will be happy to assist you in obtaining your benefits and will estimate your benefits

based upon your policy information. It is important, however, for you to understand that insurance plans very greatly so

we cannot be certain what benefits your insurance company will pay. Any question over coverage is ultimately the

responsibility of your insurance company.

PRIMARY SECONDARY

Patient's Relationship to the Policy Holder: Patient's Relationship to the Policy Holder:

[ ] Self [ ] Spouse [ ]Child [ ] Other [ ] Self [ ] Spouse [ ]Child [ ] Other

POLICY HOLDER'S INFORMATION: POLICYHOLDER'S INFORMATION:

Name: Name:

Address: Address:

Birthdate: Birthdate:

Social Security Number: Social Security Number:

Employer Name: Employer Name:

Insurance Name: Insurance Name:

Address: Address:

Telephone: Telephone:

ID # ID #

Group # Group #

ACCOUNT AGREEMENT

As the person responsible for this account, I understand that I am responsible for payment of services rendered. Payment

is due at the time of service unless other written arrangements have been made. I hereby authorize payment of

insurance benefits directly to the Dental Office, and understand that any disparity in coverage is a matter between my

insurance company and me.

Signature: Date:

PAYMENT AND COLLECTION POLICY

The following financial policies have been enacted to enable us to continue to provide the highest quality of dental care

to our patients. We value our relationship with our patients and will be happy to assist you regarding our policies and

charges.

• If you have dental insurance, we will file claims as a courtesy for our patients. We do not have a contract

with your insurance company, only you do. Most plans pay between 30 — 50% of the average dental

treatment fee. The percentage paid is usually determined by how much you or your employer has set up

with the insurance company. Insurance companies set their own fee schedules and each company uses a

different set of fees. We have no control over how your insurance pays its claims or the amount they pay.

We can only aid you in estimating your portion of the treatment cost; we at no time guarantee what your

insurance will or will not do with each claim. You will be responsible for your estimated fees and

deductible at the time of service, as well as any balance that may remain after your insurance payments

are received.

• If we have knowledge that your insurance company sends payments to you rather than our dental office,

you will be required to pay for the entire treatment at the time of services.

• If your insurance company has not paid your account within 90 days, you are responsible for the balance of

your account.

• If you do not have dental insurance, full payment is required at the time of service.

• We accept payment in the form of cash, check, debit card, Visa, MasterCard and Discover or our financial

partner, Care Credit.

• A $25.00 fee will be applied for all NSF/returned/stopped payment checks.

• If your account is referred to a collection agency, you will be responsible for all fees incurred.

Please feel free to ask any questions you may have regarding our insurance or payment policies. We are happy to help

you in any way we can regarding the processing of your insurance claims. Please sign below stating that you understand

and accept our payment policy.

Signature: Date:

BROKEN DENTAL APPOINTMENT POLICY

It is our policy to reserve time for your appointments in order to give you the best treatment possible. We honor and

value your time, and we expect that you will do the same for us. If for any reason you need to reschedule an

appointment please call us 48 hours before your reserved time so that we can give that time to someone who is

waiting. Otherwise, as a matter of mutual respect, we trust that you will set other things aside and be here as agreed.

We hate to, but we do charge for missed or broken dental appointments. If you miss an appointment, you will be

expected to pay a Broken Appointment Charge of $75 before coming in for a rescheduled appointment. If you miss a

subsequent appointment, we will ask you to pay for your next appointment in advance.

We understand that some people have unpredictable schedules, but there is usually some way — such as same day or

last minute scheduling — to accommodate almost anyone who really wants to take care of their health.

Our goal is to improve your health and well-being through quality dental care. Aiming for this, we can certainly make

our schedules work together.

Signature: Date: