WELCOME TO SEATTLE SMILES DENTAL

1325 4th Avenue, Suite 1230Seattle, Washington 98101

TEL: 206.624.1773info@seattlesmilesdental.com | www.seattlesmilesdental.com

We provide exceptional, comprehensive, minimally-invasive and conservative dental care with a focus on your comfort and happiness. We believe that a healthy mouth and smile is essential to a healthy body, and our focus is on prevention, early detection and education

so you can make informed decisions and achieve optimal oral health for a lifetime.

OFFICE HOURS 8am - 4pm8am - 4pm8am - 4pm8am - 4pm

MondayTuesdayWednesdayThursdayFriday 7am - 3:30pm

PARKING Parking is available in our building, the Puget Sound Plaza, with garage entry on the northwest side of the building just off Union Street. There are many parking garages nearby, street parking and major bus routes.

WEBSITE Please visit our website at seattlesmilesdental.com for parking, driving directions and more detailed information. Please do not hesitate to contact us with questions.

FOR YOUR FIRST VISIT• Email or mail us your completed registration forms in advance. Email us to request forms through our secure email

system. Forms may also be filled out in the office, although filling out forms in advance can help us confirm yourdental insurance benefits, if eligible.

• Bring a list of current medications, the contact information of your physician and your past dentist.• Bring your dental insurance card, if applicable.• Forward us, in advance, a copy of your most recent set of radiographs, treatment notes and plans.• Patients under 18 require a parent or guardian present to consent to treatment.• Check in 15 minutes before your scheduled appointment.

APPOINTMENTS RESCHEDULED OR CANCELED WITHIN 2 BUSINESS DAYS WILL INCUR A FEE

Name (Last, First, Middle Initial)

Social security # Date of birth

Name of parent/legal guardian

Cell phone Work phone

I prefer to receive check-up notifications by: Email

The best number to reach me is at: Home

Mail

Cell Work Other:

Emergency contact name Relationship to patient

How did you hear about our office? Who may we thank for referring you?

Date of last visit to dentist For what services?

What is the reason for today's visit?

Primary dental insurance carrier

Subscriber date of birth

Insurance phone #

Insurance address

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PATIENT INFORMATION (you must be 18 or over to fill out this form)

Preferred name

Female Male

Address City State Zip

GUARANTOR INFORMATION (person responsible for the account)

Name (Last, First, Middle Initial)

Social security #

Address (if different) City

Home phone Cell phone Email

Employer’s name Occupation Work phone

Employer’s address City State Zip

DENTAL INSURANCE INFORMATION

Subscriber name

Subscriber social security # Relationship to patient

Group # ID #

City State Zip

Check if no dental insurance

Home phone

Email

Phone #

Which describes your child's personality? friendly shy nervous strong-willed

teeth grinding/clenching pacifier use sleeping with bottle tongue thrust speech problems

Has your child experienced or used any of the following? thumb sucking nail biting mouth breathing

Has child mentioned any dental problems?

Intake fluoride in city water or supplements?

Any injuries to the mouth, teeth or head?

Does child brush teeth daily?

Does child floss daily?

Any unhappy dental experiences?

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

State Zip

Relationship to patient

Date of birth

Other:

Check if there is secondary dental insurance

YOUR CHILD'S MEDICAL HISTORY

Yes No | If yes, for what condition(s)?

Physician’s phone number

Are you under a physician’s care?

Physician’s name

Physician’s address

☐ ☐Women are you (check all that apply): nursing pregnant trying to get pregnant taking oral contraceptives

List current medications, pills, herbal supplements, drugs taken and for what condition(s):

Are you allergic to any of the following?

Yes No Yes No Yes No AIDS/HIV Alzheimer’s disease Anaphylaxis Angina (chest pain) Anxiety or panic attacks Arthritis rheumatoid osteo Artificial heart valve Artificial joint Asthma/breathing problems Autoimmune condition (e.g., lupus)

Bisphosphonate medications Blood disorder (e.g., anemia/hemophilia) Blood pressure low high Blood transfusionBruise easily Cancer/tumor Chemotherapy/radiation therapy Chronic pain (e.g., back, neck) Congenital heart disorder Dementia

Depression Diabetes type 1 type 2

Last blood sugar/A1C:

Drug/alcohol dependence Epilepsy/seizures Fainting spells/dizziness FibromyalgiaGlaucoma/eye disorder Hay fever/seasonal allergies Headaches Hearing loss/impaired Heart attack Heart trouble/disease Hepatitis A B C Herpes virus/cold sores Hives/rash Hypoglycemia Hypercholesterolemia (high cholesterol)

Jaundice Kidney problems/dialysis Liver disease Lung disease (COPD,emphysema) OsteoporosisPacemaker Parkinson’s disease Psychiatric/mental illness Rheumatic fever Scarlet fever Sexually transmitted infection Shingles Sinus trouble Sleep disorder Stomach/intestinal disorder Stroke/TIAThyroid disease Tuberculosis Ulcers

Additional notes section. If you answered yes to any of the above or have a condition not listed above, please explain here.

Date

No medications

When was your last visit to a medical doctor?

Do you have, or have you had, any of the following listed below?

no allergiesacrylic

antibioticsaspirin

codeineibuprofen/NSAIDs

latexlocal anestheticsmetals

penicillinsulfa

What was your reaction and for which medication?

List other allergies here:

If

Yes No

Have you ever been hospitalized or had a major operation? If yes, list dates and explain in notes section.

Have you ever taken/been told to take a pre-medication antibiotic before dental appointments? If yes, explain below.

Yes No

Signature of responsible party

9/2019 - 2

DENTAL HISTORY

Name of previous dentist Phone number of previous dentist

Reason you left previous dentist Date of last visit to dentist

What was completed at that time? Date of last cleaning

Date of last x-rays Reason for your visit today

Recommended dental treatment that has not been completed

Yes No Yes No

Are you having dental pain? If yes, describe: Have you worn a mouthguard or has one been recommended in the past? If you currently wear one, check all that apply:

Are you aware of clenching/grinding of teeth?

Do your jaws get stuck open or closed?

Do you have jaw pain, headaches or pain in the face, cheeks, jaw joint, throat or temples?

If so, does this pain affect your appetite, sleep, daily routine or other activities?

Have you been diagnosed with TMD (temporomandibular joint disorder)?

Are you apprehensive about dental treatment?

Have you had problems with past treatment?

Do you gag easily?

Do you wear partials or dentures?

Have you had braces or orthodontic treatment? Retainers worn? Check all that apply. over upper teeth over lower teeth

Do you frequently get canker sores/cold sores?

Have you had cavities in the past 3 years?

Teeth are sensitive to: hot cold sweets pressure

Do you get food caught between teeth, or do you have discomfort brushing or flossing around teeth?

What kind of toothbrush do you use? manual electric

How often do you brush? floss?

Have you had facial trauma or any head and neck injury?

If yes, describe:

Do you smoke: cigarettes e-cigarettes? If yes, for how long and how much? If you have quit, when?

Do you chew tobacco? If yes, for how long and how much? If you have quit, when?

Is there a history of oral cancer in your family?

If you are at risk of oral cancer, we recommend and offer annual HPV testing in our office. Please ask us for details.

Are you happy with how your teeth look/feel?

If you are interested in learning more about the following, check all that apply:

Straightening/Invisalign

Whitening

Closing spaces

Repairing chipped teeth

Replacing missing teeth

Replacing mismatched fillings/crowns

9/2019 - 3

Have you noticed recession, swollen/bleeding gums?

Have you ever had periodontal (gum) surgery or visited a periodontist (gum specialist)?

Have you ever had a deep cleaning/scaling and root planing treatment?

Have you noticed bad breath or an unpleasant taste?

Have you had loose, tipped or shifting teeth?

Is there a family history of gum disease?

Have you been diagnosed with periodontal disease

Additional notes about your dental health.

over upper teeth over lower teeth custom over-the-counter

Check if you would like us to attempt to obtain your prior dental office records

Reason for your visit today

9/2019 - 4

ACKNOWLEDGEMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Seattle Smiles Dental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is posted in the practice and available on the website.

Seattle Smiles Dental reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

By signing this agreement, I acknowledge the receipt and understanding of the Statement of Privacy Practices. In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the additional person(s) identified below.

Printed name of patient Signature of responsible party

Relationship of responsible party to patient Date

Printed name(s) and relationship to patient

I authorize the following additional person(s) access to my account:

9/2019 - 5

FINANCIAL POLICY AND CONSENT TO DENTAL TREATMENT

• Fees are due and payable at the time treatment is rendered. We accept cash, personal checks, debit cardsand credit cards (Visa, MasterCard or Discover).

• Charges incurred for services rendered are your responsibility regardless of insurance coverage.• A statement will be mailed monthly for any remaining balance.• A 1.5% monthly finance charge will be assessed on all past due accounts.• Delinquent accounts (more than 90 days past due) may be reported to a credit reporting/collection agency.• Personal checks declined by your financial institution are subject to a $25 returned check fee.• Cancellations and/or rescheduled appointments within 2 business days and broken (not showing) to

appointments will incur up to a $50 broken appointment fee per hour scheduled.• If treatment is recommended, you will receive a treatment plan with our office fee, estimated insurance

coverage as a courtesy and if applicable, and the estimated patient portion. Due to the unpredictable natureof dental treatment, the treatment plan may be modified to ensure the best treatment outcome(s).

• If you have dental insurance:o Insurance coverage is a contract between the patient and the insurance company.o We cannot guarantee your exact insurance coverage until the claim is paid. You are ultimately

responsible for fees generated by your treatment and any balance due after insurance payment.o It is your responsibility to provide us with accurate insurance information and to inform us of any

changes in your coverage as they occur.o As a courtesy, we will file the necessary forms with your insurance company to help you receive the

full benefits of your coverage.o You are responsible for all copays, coinsurance, deductibles and fees for non-covered services at the

time of service. We are required to collect your estimated copay/coinsurance and deductible at thetime of service according to your insurance company.

o We will make every effort to file and appeal claims on your behalf. However, balances not paid byyour insurance within 90 days will be your responsibility. If an appeal and payment is granted byyour insurance after this time, you will receive a credit to your account.

o We will file your primary and secondary insurance, if applicable, as a courtesy. Secondary insurancestypically pay according to a coordination of benefits with the primary insurance. Having secondaryinsurance does not necessarily mean that services will be covered at 100%.

By signing this agreement, I consent to dental treatment by Seattle Smiles Dental. I assign directly to Seattle Smiles Dental all insurance benefits, if any, otherwise payable to me for services rendered. I am responsible for charges incurred for dental services to me or my dependents in this office. I authorize Seattle Smiles Dental to collect all information necessary (e.g., radiographs, photographs, periodontal charting, tooth records, written reports) to provide my dental care and to submit this information to my insurance if required.

Printed name of patient Signature of responsible party

Date Relationship of responsible party to patient