Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help.

Date: _______ /_______ /________E-Mail: _________________________Cell Phone:(_______)________-________D.O.B. _________/_______/________

DO YOU HAVE ADDITIONAL DENTAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING Name of Insured __________________________________Relationship to Patient___________________ D.O.B_____/_____/_______Social Security #_______-_______-________Name of Employer___________________________Insurance Company___________________________Group #___________________________________Policy/ID # __________________________________

Over Please

WelcomePatient Information (Confidential) Name______________________________________________ Social Security #: _____-_____-______ HomePhone________________Address____________________________________________ City_____________________State ________ Zip __________

Check the Appropriate Box Minor Single Married Divorced Widowed Separated

Responsible Party Information (If other than self)

Name of Person Responsible for this account_________________________________________________ Address________________________________City___________________State__________Zip________ Birth date of Person Responsible________/_______/_______Is this Person currently a patient in our office? Yes________ No ________

Emergency Contact___________________________________ Phone:____________________________

Whom may we thank for referring you? (Circle your choice)

SaveOn

Building Sign

Local Paper

Postcard

Valpak

Friend/Family Member:__________________________

Other:__________________________________________________________________________________

Dental Insurance InformationName of insured_________________________________Relationship to Patient____________________ D.O.B._____/______/_______Social Security #_______-______-_______Name of Employer___________________________Insurance Company___________________________Group #___________________________________Policy ID #__________________________________

Patient Dental HistoryName of Previous Dentist & Location ______________________________________ Date of Last Visit __________________

Reason for Leaving ___________________________

Authorization & ReleaseI certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment of examination rendered to me or my child during the period of such dental care to third-party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. 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 behalf or on behalf of my dependents.

X (Signature of patient or parent if a minor) ______________________________________________ Date_____________________

1. Are you under medical treatment now? ..........................

2. Have you ever been hospitalized for any surgicaloperation or serious illness within the last 5 years? ...... If yes, please explain___________________________ ___________________________________________

3. Are you taking any medication(s)including non-prescription medicine? ............................ If yes, what medications are you taking?______________________________________________________________________________________

4. Do you use tobacco?.......................................................

5. Do you use controlled substances?.................................

6. Are you wearing contact lenses?.....................................

7. Do you have or have you had any of the following?

Yes NoHigh Blood Pressure ................ Heart Attack ............................. Rheumatic Fever ...................... Swollen Ankles ......................... Fainting Spells .......................... Asthma ...................................... Low Blood Pressure ................. Epilepsy/Convulsions ............... Leukemia .................................. Diabetes ................................... Kidney Diseases ....................... AIDS/HIV Infection .................. Thyroid Problem ......................

Yes No1. Do your gums bleed while brushing or flossing? .............. 2. Are your teeth sensitive to hot or cold liquids/foods? ....... 3. Are your teeth sensitive to sweet, sour liquids/foods? ....... 4. Do you feel pain in any of your teeth?............................... 5. Do you have any sores or lumps in or near your mouth?.. 6. Have you had any head, neck or jaw injuries?..................

If yes, explain __________________________________ 7. Have you ever experienced any of the following

problems in your jaw? If yes, please explain:Clicking.............................................................................. Pain (joint, ear, side of face) ..............................................

Difficulty in opening or closing ____________________ Difficulty in chewing ..........................................................

Yes No8. Do you have frequent headaches? ..................................

9. Do you clench or grind your teeth? ................................

10. Do you bite your lips or cheeks frequently? ....................

11. Have you had any difficult extractions in the past? ........

12. Have you had prolonged bleeding after extractions? .....

13. Have you had any orthodontic treatment? ......................

14. Do you wear dentures or partials? ................................. If yes, date of placement _________________________

15. Have you ever received oral hygiene instructionsregarding the care of your teeth and gums?.....................

16. Do you have problems with snoring?............................... 17. Is there anything you would like to change about your

smile? ______________________________________________________________________________

Yes No

Cardiac Pacemaker .................. Heart Murmur .......................... Angina ...................................... Heart Trouble ........................... Mitral Valve Prolapse ............... Emphysema .............................. Cancer ...................................... Arthritis .................................... Joint Replacement/Implant ....... Hepatitis/Jaundice .................... Sexually Transmitted Disease ... Stomach Trouble/Ulcers ...........

Yes NoChest Pains ............................... Easily Winded ........................... Stroke ....................................... Hay Fever/Allergies ................. Tuberculosis ............................. Radiation Therapy .................... Glaucoma ................................. Recent Weight Loss .................. Liver Disease ........................... Frequently Tired ....................... Respiratory Problems ............... Anemia ..................................... Other ........................................

Patient Medical HistoryPhysician_________________________________ Office Phone______________________ Date of Last Exam _____________ Specialist______________________________________ Yes No Yes No

8. Are you allergic to or have you hadany reactions to the following?

Local Anesthetics (e.g. Novocaine) ........ Penicillin or any other antibiotics ......... Sulfa Drugs ............................................ Iodine ..................................................... Aspirin ................................................... Any Metals (e.g. nickel, mercury, etc.) ... Latex Rubber.......................................... Other (please list)...................................

9. Women Only:a) Are you pregnant or think

you may be pregnant? ........................ b) Are you nursing?................................ c) Are you taking oral contraceptives? ..

Heart Disease ............................

Patient Acknowledgment & Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act or 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This notice contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgement) that we first obtain your written consent prior to disclosing any of your information except to our disclosures in connection with any of the following: a defense to claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to, or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing, or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient acknowledgement

Please sign this form to acknowledge that you have received a copy of our notice of privacy practices & consent. Also, that you agree to our office disclosing information to other health care professionals or to your family members concerning your treatment.

Please list the names of people we may discuss treatment with/disclose your information to:

___________________________________________________________________________________________________________

Patient Consent

__________________________________________________________________________________________________________ Patient/Guardian Signature Date Patient Name (Please Print)

***********************************************For office use only *********************************************** Patient refused to sign The following circumstances prohibited the patient from signing the acknowledgement:

___________________________________________________________________________________________________________

An emergency situation prevented the patient from signing the acknowledgment:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________ Office Personnel Signature

Date Office Personnel (Please Print)

Written Financial Policy Thank you for choosing Tina Marshall DDS PC! Our primary mission is to deliver the best and most

comprehensive dental care available. In order to accomplish this mission, we make the cost of optimal care easy and manageable for our patients by offering several payment opportunities.

PAYMENT OPTIONS

You can choose from: - Cash : Check : Visa : MasterCard : Discover Card

-We offer personalized discounts when full payment is made up front.

- Care Credit-Allows you to pay over a period of time-No annual fees or pre-payment penalties-Convenient monthly payments

Please note:

Tina Marshall DDS PC requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.

Affordable payment plans available for all patients.

For patients with dental insurance, we are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement for your treatment.2

A fee of $25/hour is charged for patients who miss or cancel more than 3 times in a calendar year without 24 hour notice.

Tina Marshall DDS PC charges $30 for returned checks.

If you have any questions, please do not hesitate to ask!

_____________________________________________________________________________________ Patient, Parent, or Guardian Signature Date

_____________________________________________________________________________________ Patient Name (Please Print) 1

Subject to credit approval 2

However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.