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1. PATIENT INFORMATION

LEGAL NAME__________________________________________________________________________

LAST FIRST MIDDLE PREFERRED

ADDRESS ___________________________________________________________________________

CITY, STATE, ZIP ____________________________________________________________________

EMAIL __________________________________________________________________________

MALE FEMALE

PATIENT EMPLOYER: __________________________________________

DATE OF BIRTH ____________________________SOCIAL SECURITY # ____________________________

MARRIED SINGLE DIVORCED WIDOWED STUDENT

SPOUSE NAME _________________________________SPOUSE EMPLOYER ______________________

WHO MAY WE THANK FOR REFERRING YOU? ________________________________________________

PHONE NUMBERS:

HOME (_____) ________________________ WORK (_____) _________________________

CELL (_____) ________________________ SPOUSE’S WORK (_____) _________________

BEST TIME TO CALL __________________

MAY WE CALL YOU AT WORK? YES NO MAY WE TEXT YOU? YES NO

HAVE YOU BEEN TREATED BY ANOTHER DENTIST IN THE LAST 12 MONTHS ? YES NO

NAME OF DENTIST ___________________________Reason _____________________________

2. DENTAL INSURANCE

RESPONSIBLE PARTY (“SELF” IF SELF) _______________________________________________________

INSURANCE COMPANY __________________________________________________________________

GROUP # _____________________________________ POLICY # _______________________________

SUBSCRIBER’S NAME _______________________________EMPLOYER___________________________

DATE OF BIRTH ________________________________ SOCIAL SECURITY # _______________________

IS THE PATIENT COVERED BY ADDITIONAL INSURANCE? YES NO

INSURANCE COMPANY __________________________________________________________________

GROUP # _____________________________________ POLICY # _______________________________

SUBSCRIBER’S NAME _______________________________EMPLOYER___________________________

DATE OF BIRTH ________________________________ SOCIAL SECURITY # _______________________

X

SIGNATURE OF PATIENT, OR LEGAL GUARDIAN

X

PRINTED NAME OF PATIENT, OR LEGAL GUARDIAN

X X

DATE RELATIONSHIP TO PATIENT (“SELF” IF SELF)

MEDICAL HISTORY

Patient Name: ___________________________

Physician’s Name __________________________________ Date of last visit _______________

1. Are you currently under medical care? Y / N For what condition? _________________

2. Are you taking any medications? Y / N

3. Do you smoke? Y / N Packs per day: ___________

4. Alcohol use? Y / N Amount: _________ per day / week / month

5. Are you pregnant? Y / N Due Date: ____________

6. Have you had allergic reactions to any of the following:

|Local (dental) anesthetic |Yes |No |

|Penicillin or other antibiotics |Yes |No |

|Barbiturates (sleeping pills) |Yes |No |

|Sedatives : ___________________________ |Yes |No |

|Pain medicine : _______________________ |Yes |No |

|Other allergies : (list) _____________________ |Yes |No |

7. Please check all that apply and list medication(s) on space provided:

| |AIDS/HIV |_________________ | |Hepatitis : A B C |___________________ |

| |Anemia |_________________ | |Herpes |___________________ |

| |Arthritis |_________________ | |High Blood Pressure |___________________ |

| |Artificial Heart Valve |_________________ | |Jaw Pain |___________________ |

| |Artificial Joint |_________________ | |Kidney Disease |___________________ |

| |Asthma |_________________ | |Liver Disease |___________________ |

| |Bleeding disorder |_________________ | |Low Blood Pressure |___________________ |

| |Blood disease |_________________ | |Mitral Valve Prolapse |___________________ |

| |Cancer |_________________ | |Nervous Problems |___________________ |

| |Current/Past Drug use |_________________ | |Pacemaker |___________________ |

| |Chemotherapy |_________________ | |Intellectual Disability/ ADHD/ADD | |

| |Cannabis/Marijuana use | | |Bipolar/Anxiety/Depression | |

| |Congenital Heart Disease |_________________ | |Radiation |___________________ |

| |Cortisone/Steroid Treatments |_________________ | |Respiratory Problems |___________________ |

| |Cough Persistent/Bloody |_________________ | |Rheumatic/Scarlett Fever |___________________ |

| |Diabetes-Type I or II |_________________ | |Shortness of Breath |___________________ |

| |COPD |_________________ | |Stroke |___________________ |

| |Epilepsy |_________________ | |Thyroid Problems |___________________ |

| |Fainting or dizziness |_________________ | |Tonsilitis/Sinusitis |___________________ |

| |Headaches |_________________ | |Tuberculosis |___________________ |

| |Heart Problems or bypass/stent: |_________________ | |Venereal Disease |___________________ |

| |Blood thinners |_________________ | |Osteoporosis |___________________ |

Other medical or oral health problems not listed above:_______________________________________

_____________________________________________________________________________________

Patient’s/Guardian’s Signature ___________________________________Date_____________

PATIENT CONSENT & HIPAA

Consent for: ________________________________________________ (Print your or patient’s Name)

I understand that I have certain rights to privacy regarding my protected health information (PHI). These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize this Practice to use and disclose my PHI to carry out treatment, obtain payment and information from third party payers and carry out day-to-day operations of the Practice.

I have also been given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my PHI. I understand that you reserve the right to change the terms of this notice and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my PHI is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you will then comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. This consent will end when my treatment plan is complete or one year from the date signed below. I also assign, directly to this Practice, insurance benefits and give permission for this Practice to use my health care information and disclose my information in order to obtain payment and determine insurance benefit.

I give consent for comprehensive dental treatment by Smudde Family Dentistry, including any tests necessary for diagnostic purposes. Comprehensive dental treatment includes examination, teeth cleaning, fluoride application, restorations (fillings), teeth whitening, crowns, endodontic treatment (tooth nerve treatment), extractions, tooth replacement and orthodontics. I also give consent for this Practice to discuss my treatment with other health care professionals as necessary for my care.

You may also disclose information to the following people, or contact them on my behalf or in case of emergency: (PLEASE ENTER A PHONE NUMBER OTHER THAN YOUR OWN)

|Name |Phone Number |Relationship to Patient |

| | | |

| | | |

You may leave messages regarding my Protected Health Information on the following:

Home phone _(_____)________________ Cell phone _(_____)____________________

Text message _(_____)________________ Work phone _(_____)____________________

Other- _____________: (_____)__________ Email ? YES NO

Signature of Patient or Legal Guardian Date

Printed name Relationship to Patient (if Guardian)

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PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIES

Smudde Family Dentistry believes that part of good dental care practice is to establish and communicate office and financial policies to our patients. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.

PAYMENT: PAYMENT IS DUE AT TIME OF SERVICE. We accept Cash, Check, Visa, MasterCard, & Care Credit. Payment will include any unmet deductibles, estimated co-payments, any charges not covered by your insurance coverage (including treatment after maximums are met), as well as any outstanding balances. If you do not carry insurance, payment is due in full at the time of your visit.

INSURANCE: We are a participating provider with most insurance plans. We will file claims on your behalf for these plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment. As a courtesy to our patients, we will attempt to verify your insurance coverage, however, our verification is not a guarantee of benefits payable by your insurance.

*It is ultimately your responsibility to know your insurance benefits and we cannot guarantee payment by your insurance company. We must have complete and up-to-date insurance information in order to bill on your behalf. If we do not receive payment from your insurance company within 45 (forty-five) days, payment becomes your responsibility.

RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible for charges not covered by the assignment of insurance benefits and all non-covered charges.

COLLECTION FEES: Accounts that remain unpaid after 45 days may be turned over to our internal collection department. When an account becomes 90 days past due, collection action may be taken outside of Smudde Family Dentistry. In this event, you agree to pay an additional $50.00 fee to cover the fee imposed to Smudde Family Dentistry by the collection agency as well as any other collection, legal, interest and filing fees.

RETURNED CHECKS will incur a $45.00 service charge.

CANCELLATIONS: We understand that situations may arise in which you must cancel or change your appointment. We request that you provide at least 24-hour notice for this change. Patients who do not show up, nor provide more than a 24-hour notice, are considered a NO SHOW and will incur a $65 charge for the time allotted for their appointment. Patients who No-Show two (2) or more times in a 12-month period, may be dismissed from the Practice.

If you are more than 15 minutes late for your appointment, you may be asked to reschedule so we can attempt to stay on time for other scheduled patients.

I, the undersigned, have read and understand the practice’s office and financial policies and I agree to be bound by its terms, and assuming financial responsibility as stated above.

I also understand and agree that such terms may be amended by the Practice at any time.

X__________________________________________ ________________________

Signature of Responsible Party Date

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SMUDDE FAMILY DENTISTRY, Inc.

Meredeth Gray, D.D.S.

1608 Lafayette Avenue, Terre Haute, Indiana 47804

Phone 812-466-9826 Fax 812-466-1720

SMUDDE FAMILY DENTISTRY, Inc.

Meredeth Gray, D.D.S.

1608 Lafayette Avenue, Terre Haute, Indiana 47804

Phone 812-466-9826 Fax 812-466-1720

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