PATIENT INFORMATION (CONFIDENTIAL)

NAMEFIRST Ml LAST

ADDRESS CITY

E-MAIL CELL PHONE

SS#/SIN BIRTHDATE

CHECK APPROPRIATE BOX: D MINOR D SINGLE D MARRIED D

IF COLLEGE STUDENT, F.T. / P.T., NAME OF SCHOOL

PATIENT'S OR PARENT'S/GUARDIAN'S EMPLOYER

BUSINESS ADDRESS CITY

SPOUSE OR PARENT'S/GUARDIAN'S NAME EMPLOYER

DATE

STATE/PROV.

HOME PHONE

DIVORCED D WIDOWED

CITY

WORK PHONESTATE/PROV.

WORK PHONE

~A

ZIP/PC.

D SEPARATEDSTATE/

PROV.

ZIP/P.C.

WHOM MAY WE THANK FOR REFERRING YOU?

PERSON TO CONTACT IN CASE OF AN EMERGENCYV

PHONE

RESPONSIBLE PARTY

NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT

ADDRESS

DRIVER'S LICENSE # BIRTHDATE

EMPLOYER

IS THIS PERSON CURRENTLY A PATIENT IN OUR OFFICE? D YESV

~\P

TO PATIENT

HOME PHONE

SS#/SIN

WORK PHONE

D NO

INSURANCE INFORMATION

NAME OF INSURED

BIRTHDATE SS#/SIN

NAME OF EMPLOYER

EMPLOYER ADDRESS

INSURANCE CO.

INS. CO. ADDRESS

HOW MUCH IS YOUR DEDUCTIBLE?

UNION OR LOCAL #

CITY

TEL. # GRP #

CITY

HOW MUCH HAVE YOU USED?

1

RELATIONSHIPTO PATIENT

DATE EMPLOYED

WORK PHONESTATE/ ZIP/PROV. P.C.

POLICY /I.D. #STATE/ ZIP/PROV. P.C.

MAX ANNUAL BENEFIT?

DO YOU HAVE ANY ADDITIONAL INSURANCE? Q YES Q NO

NAME OF INSURED

BIRTHDATE SS#/SIN

NAME OF EMPLOYER

EMPLOYER ADDRESS

INSURANCE CO.

INS. CO. ADDRESS

HOW MUCH IS YOUR DEDUCTIBLE?

UNION OR LOCAL #

CITY

TEL. # GRP #

CITY

HOW MUCH HAVE YOU USED?

IF YES, COMPLETE THE FOLLOWING:

RELATIONSHIPTO PATIENT

DATE EMPLOYED

WORK PHONESTATE/ ZIP/PROV. P.C.

POLICY /I.D. #STATE/ ZIP/PROV. P.C.

MAX ANNUAL BENEFIT?V

XSIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR PATIENT NUMBER

REGISTRATI

TIME 4:21 PM Elite Dentistry DATE 3/5/2013

MEDICAL HISTORY

PATIENT NAME Birth 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 mayhave, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

following questions.1

Are you under a physician's care now? Q Yes O No IfHave you ever been hospitalized or had a major operation? Q Yes O No 1

yes, please explain:

yes, please explain:

Have you ever had a serious head or neck injury? Q Yes O No If yes, please explain:Are you taking any medications, pills, or drugs? O Yes O No If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux? Q Yes Q NoHave you overtaken Fosamax, Be

other medications containin

Are yoD

Do you use con

niva, Actonel or any ,-x ., ,-. ^,g bisphosphonates?^ Tt-°^ INU

u on a special diet? O Yes O Noo you use tobacco? O Yes Q No

trolled substances? O Yes O No

Pregnant/Trying to get pregnant? O YesO No Taking oral contraceptives? O YesO No Nursing? O YesO No

-Are you allergic to any of the followin

| | Aspirin | Penicillin |

| (Other If yes, please explain:

_0g '^] Codeine | | Local Anesthetics | | Acrylic j Metal Q Latex Sulfa drugs

- -Do you have, or have you had, any o

AIDS/HIV Positive Q Yes O NOAlzheimer's Disease O Yes O NoAnaphylaxis O Yes O NoAnemia Q Yes Q NoAngina O Yes Q NoArthritis/Gout O Yes Q NoArtificial Heart Valve Q Yes Q NoArtificial Joint O Yes Q NoAsthma O Yes Q NoBlood Disease O Yes O NoBlood Transfusion O Yes O NoBreathing Problem O Yes O NoBruise Easily O Yes Q NoCancer O Yes O NoChemotherapy O Yes O NoChest Pains O Yes Q NoCold Sores/Fever Blisters Q Yes O NoCongenital Heart DisorderQ Yes O NoConvulsions Q Yes Q No

Have you ever had any serious illne

Cortisone Medicine Q Yes O NoDiabetes O Yes O NoDrug Addiction Q Yes Q NoEasily Winded Q Yes O NoEmphysema Q Yes 0 NoEpilepsy or Seizures Q Yes O NoExcessive Bleeding Q Yes O No

Excessive Thirst Q Yes O NoFainting Spells/Dizziness Q Yes Q NoFrequent Cough Q Yes Q NoFrequent Diarrhea Q Yes O No

Frequent Headaches Q Yes O NoGenital Herpes Q Yes Q NoGlaucoma Q Yes O NoHay Fever Q Yes Q NoHeart Attack/Failure Q Yes O NoHeart Murmur Q Yes O NoHeart Pacemaker Q Yes O NoHeart Trouble/Disease Q Yes O No

ss not listed above? O YSS O No

Hemophilia Q Y£S O NoHepatitis A O Yes O NoHepatitis B or C O Yes O NoHerpes O Yes O NoHigh Blood Pressure Q Yes Q NoHigh Cholesterol Q Yes O NoHives or Rash Q Yes Q NoHypoglycemia O Yes O NoIrregular Heartbeat O Yes O NoKidney Problems Q Yes Q NoLeukemia O Yes Q NoLiver Disease Q Yes Q NoLow Blood Pressure Q Yes Q NoLung Disease O Yes O NoMitral Valve Prolapse Q Yes Q NoOsteoporosis O Yes O NoPain in Jaw Joints O Yes Q NoParathyroid Disease Q Yes Q NoPsychiatric Care O Yes Q No

Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Comments:

O Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O NoO Yes O No iO Yes O No !O Yes O No iO Yes O No !O Yes O No IO Yes O No iO Yes O No |O Yes O No

J

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

100 Chelsea Corners Way Suite 113Chelsea Al, 35043205-678-2525—DENTISTRY

Disclosure of Treatment Form

By signing below, you hereby consent for Keith Davis D.M.D., LLC (the practice) to use ordisclose information about you or another person for whom you have given the authority to signthat is protected under federal law, for the sole purposes of treatment, payment, and health careoperations. You may refuse to sign this consent form. You may read the Notice of PrivacyPractices for PHI, available at the front desk before signing this consent. The terms of theNotice may change from time to time and you may always get a revised copy of it by asking theoffice manager.

You also have the right to request that the practice restrict how your PHI is used ordisclosed in carrying out treatment, payment, or health care options. Please be aware; however,that the Practice is not required to agree to these certain restrictions, Should the practice agree toyour request restrictions, though, these restrictions are binding.

Information about you in protected under federal law, and you have the right to revokethis consent at any time. By signing below, you recognize that the protected health informationused or disclosed may be subject to re-disclosure by the recipient and may no longer be protectedunder law.

Keith L. Davis D.M.D., LLC may communicate confidential information, including paymentinvoices, appointment reminders, treatment, and insurance to all phone numbers or addressesprovided by mail, phone call, or text message. I also authorize email if I have provided one.

I authorize the following persons to communicate with the office on my behalf concerning mymedical care.

Name Relationship

Name Relationship

Billing PolicyThis is to inform you that it is the policy of this office that after three billing cycles with no

payment, your account will be turned over to a collection agency. By signing below, I understandthat I accept the fee(s) as a legal and lawful debt. I understand the fee(s) are due at the time ofservice. Should it become necessary to forward my account to collection, I agree to pay all moniesdue, including a 33% collection fee, Attorney's fee, and/or Court Costs, if such be necessary. Iwaive now and forever my right of exemption under the laws of the Constitution of the State ofAlabama and any other state.

Insurance WaiverInsurance is a contract between the patient and their insurance. Our office will file

insurance for our patients as a courtesy, but it is the responsibility of the patient to know howtheir insurance pays.

Signature Date