DENTALREGISTRATIONAND HISTORY

STEVEN M. STANLEY, D.D.S., PLLC1515 No rth 200th St.Shoreline, WA 98133

Telephone: (206) 542-1196(PLEASE PRINT)

Oate _ Home Phone ( ) _ Cell Phone ( ) _

PATIENT INFORMATION

MidciielnitialSS/HIO/Ratient ID J!#.~~,.,.,...,.~,."...._~~"....o.."""F~

~ast Name

o Married 0WidowedDSeparated 0 Divorced

Occupation ~~~+4",4,;~~~~¥'P"~~~~

State _;---~-,.

PRIMARY INSURANCE

Name of Insurance Company(ies)• Dr.. all insurance benefits, if any, otherwise payable to me for services t~nli:lered. I understand

that Iam financially responsible for aU charges whether' or hot paid by insurance. I authorize the use of my slqnature on all- insurance submissions.

The above-named doctor may use my heeilt" care infcir,mation and may disclose such information to the above-named Insurance C0mf'any(ies,) andtheir ag,ents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable fOf related services. Thisconsel'll will ena when my current treatment plan is completed or one year from the date signed below. .

Signature of Patient, Parent, Guardian or Personal Representative bate'

Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

(Vers.D2ISS04) #10512 - © 2004 Medical Arts Press" 1-800-328-2179

DENTAL HEALTH HISTORY(Confidential)

DENTAL HISTORY

Reason for Today's Date of last dental care .,----.~---',-,---"-~-,-'----.,..~".+'~~...",f~~~--

Date of last dental X-rays "7'-"=-,.=~""","~~-?--"o.=._*~~~~~-

o Sensitivity to hot

o $ensitivity to sweets

o Sensitivity When bftin@

o SOres orgrowth~. in yoltJrmouth

How often do you brush? -.-:. .....•.... ,..- -'-:-_

MEDICAL HISTORY

Address __ ~~------~~~~ ~~~~~~------------~------~~-~-~~~~Check ( .I ) if you have had problems With any: of the'folJowingo Sad breath .. • LJ (jrinding teeth

o Loose teeth.or broken fillings

D Perjooontal treatment

o Sensitivity to cold

Physician's Name -..,... ~_---~--- Date of Last Visit __ - __ ---'------

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These inolude combinations of lonimin, Adipex, Fastin (brandnames of phentermine), Pondimin (fenfluramine) and RedlJx. (c{eX.fenfluramine.) 0 Yes 0 No

Have you had any serious iJlne·sses or operations? ...,.........•..-,.__------

Have you ever had a blood transfusion? DYes DNal! yes, give approximate dates_~"-,-~~~~_~"""", __ ~---'7:"-"-"';""' __

(Women) Are you pregnant? 0 Yes (] No

If yes, describe '--'-_--".."......-"- -::.. _

NtJrsing? DYes D No Taking birth control pills? 0 Yes 0 No

Check ( ,/ ) i.l you have or have had any of the following:

(] Anemia (J Cortisone Treatments

o Arthritis, Rheumatism D Oough, Persistent

(] ArUficial Heart Valves 0Cough up Blood

DArfificialJoints 0 Diabetes

o Asthma 0 Epilepsy

(] Back Problems 0 FaiAling

o Blood Disease (] Glaucoma

o Cancer (] Headaches

DChemioal Dependency (] Heart Murmur

o Chemotherapy (] Heart Problems

DCirculatory Problems 0Hemophilia

• •

o Hepatitis

o High Blood Pressure

DHIV/AIDS

o Jaw Pain

o Kidney Disease

o Liver Disease

o Mitral Valve Prolapse

o Pacemaker

o Radiation Treatment

o Respiratory Disease

o Rheumatic Fever

OScarlet Fever

oShottness of Breath

OSkinRash

OStroke

D"Swellirig of Feet or Ankles

o Thyroid Problems

o Tooaceo Habit

o TOnsillitis

o Tubercul0sis

DUlc€r ,.

o Venereal Disease

ALLERGIES

o Aspirin

o Barbiturates (Sleeping pills)

o Codeine

o Local Anesthetic

o Penicillin

LiSulfa

SIGNATURE

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of hiS/her staff responsibletor any errors or omissions that I may have made in the completton of this form.

Steven M. Stanley, DDS PLLC 1515 North 200th Street Shoreline, WA 98133

(206) 542-1196 As a courtesy to our patients, our office is more than willing to assist you with your insurance to insure a smooth billing process. We will directly bill your insurance company. Since your insurance company is a contract agreement with you, we cannot guarantee any insurance coverage or payments. I understand the above statement and authorize the release of treatment information. All dental benefits are to be paid directly to Steven M Stanley, DDS PLLC. All dental charges incurred by myself and my family will otherwise be my responsibility. It is my understanding that I will receive a late processing fee of 1% or an annual percentage rate of 12% per year on those charges not paid in full within ninety days of the original date I was billed for my charges. There is a $1.00 minimum late processing fee. If for any reason it is necessary to be turned over to collections, I agree to pay collection fees, and should legal action be filed, reasonable attorney fees, filing fees, and other costs the court determines proper. If monthly payments are arranged, I accept the terms and conditions as disclosed above.

Changing appointment notice: Should a scheduling conflict arise, please give our office at least 2 business days notice so that we may reschedule you properly as well as serve our other patients. Because late cancellations may prevent us from being able to appoint another patient during your time, we will charge an administrative fee of $65.00, which will not be covered by your insurance. This fee will also be charged if you fail to show up for your scheduled appointment. The fee must be paid prior to your next appointment.

Dental Procedures Requiring Lab Work:

A 50% deposit is due at or before initial prep appointment for all procedures that require lab work. (Eg. Crowns, implant crowns, bridges, partial dentures, realigns, night guards etc.) Signature________________________________________________Date________________

AUTHORIZATION TO RELEASE INFORMATION

Please mail to your previous dentist

Patient Name __________________________

Address _________________________

City, State, Zip __________________________

Phone Number __________________________

I authorize the release of the following:

Panoramic or Full Mouth Xrays – within past 5 years

Bitewing Xrays – within past 12 months

Periochart

Release From:

Name _____________________________

Address _____________________________

City, State, Zip _____________________________

Phone Number _____________________________

Send to:

Name Steven M. Stanley, D.D.S.

Address 1515 North 200th Street

City, State, Zip Shoreline, WA 98133

Phone Number 206/542-1196 or email office@stevestanleydds.com

Patient Signature ________________________

Date ________________________