Welcome to Sequim Family Dentistry Dr. Nathan E. Gelder DMD

321 N Sequim Ave. #B/ PO Box 3430 360-681-8884 (TUTH)

www.sequimfamilydentistry.com

YOUTH INFORMATION

Full Name:_________________________________ I prefer to be called:________________

Male:___ Female:___ Birthdate: __/__/__ Age:___ SSN#(if billing insurance):______________

Home Address:________________________________________________________________

Mailing Address (if different than home address):_____________________________________

Home Phone #: (___) _________________ Cell #: (___) __________________

PARENT/GUARDIAN/RESPONSIBLE PARTY INFORMATION

Full Name:_________________________________ Birthdate: __/__/__ SSN# :______________

Home Address:________________________________________________________________

Mailing Address (if different than home address):_____________________________________

Home Phone #: (___) _________________ Work #: (___) __________________

Cell#: (___) _________________ Email address: ___________________________________

How do you prefer to receive billing statements? E-mail USPS mail Both mail & e-mail

Employer:_______________________ # Years Employed:___ Occupation:________________

Whom may we thank for referring you? ____________________________________________

DENTAL INSURANCE INFORMATION (if applicable)

Primary Dental Insurance: Insurance Company Name:___________________________ Phone #: (___) _______________

Insurance Co. Billing Address:_____________________________________________________

Subscriber Name: __________________________ Relationship to patient:___________________

Subscriber Date of Birth ___/___/____Subscriber ID #:__________________ Group #:__________

Secondary Dental Insurance: Insurance Company Name:___________________________ Phone #: (___) _______________

Insurance Co. Billing Address:_____________________________________________________

Subscriber Name: __________________________ Relationship to Patient:___________________

Subscriber Date of Birth ___/___/____Subscriber ID #:__________________ Group #:__________

(OVER)

http://www.sequimfamilydentistry.com/

FULI NAME: DENTAT HISTORY S.F.D. lP.O.Box 3430lSequim 98382

lChy have you come to the dentist today? Have you experienced problems with dental work? If yes,

explain Are you happy with the way your smile looks? If not, what would you want to

change? Are any of your teeth sensitive to hot, cold, or anything else? (explain)

PTEASE CHECK THE FOLLOI7ING THAT APPLY: Jaw joint pain?_ Apprehensive about dental treatment? Grindor Clench teeth? Gums bleed, feel teoder or are irritated? Periodontal Disease?

- Dry Mouth?- Prev. Ortho?-

DO YOU REQUIRE DENTAL ANTIBIOTICS PRIOR TO DENTAL PROCEDURES? (if yes, please list directions of what you take):,

Previous Dentist (name/city/state & date of last visit)

MEDICAT HISTORY

Physician's Name:

Are you currently under the care of a physician? (if yes, please explain)

Add."sr hone#:

Do you smoke or use tabacco in any form?

PLEASE LIST ANYTHING THAT YOU ARE ALLERGIC TO:

Are you currently pregnart or nursing? (please specify):

AttERGIES

PLEASE LIST ALL THE MEDICATIONS

MEDICATIONS-attach list or note belowTHAT YOU ARE TAKING (Prescription and over-the-counter **for prescription RX's please note

what health problem theyrre taken for):

PLEASE CIRCLE ANY OF THE FOLLO\TING WHICH YOU HAVE OR HA]ILHAD

Abnormal Bleeding Chicken PoxAlchohol Abuse ColitisAnemia

Angina Pectoris DiabetesArthritis

ArtificialBones/Joints DrugAbuseArtificial Valves EmphysemaAsthma

Hay Fever

Headaches

Congential Heart Defect Heart Attack

Kidney Problems SeizuresLiver Disease ShinglesLow Blood Pressure Sickle Cell Disease

Sinus Problems

Mitral Valve Prolapse Steroid TherapyDifficultySwallowing HeartSurgeryHeart Murmur Lupus

Hemophilia

Hepatitis/ A B C

Herpes

Osteoporosis

Pacemaker

Stroke (list date below)

Thyroid Problems

Epilepsy Psychiatric Problems TonsillitisBlood Transfusion Fainting Spells High Blood Pressure Radiation Treatment Tuberculosis (TB)Cancer(list type below) Fever BlistersChemotherapy Glaucoma

HIV+ / AIDSHospitalized(list reason below) Scadet Fever Venereal Disease

Please list serious medical conditions and dates they happened:

Rheumatic Fever Ulcers

AUTHORIZATIONS*I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is myresponsibility to inform this office of any changes in my medical status. (sign & date).*I understand that where appropriate a credit bureau report may be obtained.(sign & date).*I certify that I am covered by Insurance Co. and I assign beoefits directly to Dr. Brian L. Juel D.D.S. 'l'I understand thatI am responsible for payment of services rendered as well as co-pays, deductibles or other services that my insurance does not cover. I herebyauthorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all mysubmissions, whether manual or electronic. (sign & date)

Acknorwledgernent ofStaternent of Prirzac)'

Receipt ofPractices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of SequimFamily Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of myprotected health information that might occur in my treatment, payment for seruices, or in theperformance of office health care operations. The Statement of Privacy Practices also describes my rightsand the responsibilities and duties of this office with respect to my protected health information, TheStatement of Privacy Practices is also posted in the facility.

Sequim Family Dentistry reserves the right to change the privacy practices currently described in theStatement of Privacy Practices. If privacy practices change, I will be offered a copy of the revisedStatement of Privacy Practices at the time of my first visit after the revisions become effective. I mayalso obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwisetransmitted to me.

OFFICE USE ONLY BELOW THIS LINE

Sequirn Family Dentistry321 North Sequim Avenue I PO Box 3430 - Sequim " Washington '' 98382 - 360-681-8884

ADDTTIONAL DISCLOSURE AUTHORIZATION

ln addition to the allowable disc/osures described in the Statement of Privacy Practices, I herebyspecifically authorize disclosure of my Protected Healthcare lnformation to the person(s) identifiedbelow. (l understand that the default answer is "NO". Without indicating "YES" in answer to the eachindividual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowedby HIPAA rules.)

Spouse only tr YES trNOAnv Member of mv immediate familv: (Spouse. Children. Children's Spouses) tr YES trNOAny Member of my extended family: (Parents, Grandchildren) tr YES trNO

Other: tr YES !NOName of patient (please print):

Patient siqnature:

Patient's personal reDresentative: (Please Print):

Personal Representative's siqnature:

Representative's Telephone Number: Date:

Ackno\nzledget.rlent Not ObtainedProvided Prior toTreatment? tr YES fr No Date Statement Provided:

Reason for not obtainingpatient signature

n Needed more time to review Statement of PrivacyPractices

u Wanted to consult another person before signingD Physically unable to sign

D No reason offered

n Other: