TIME 10:51 AM

PATIENT REGISTRATION

DATE 6/22/2012

Patient Information

Additional Comments:

Primary Insurance Information

Responsible Party (if someone other than the patient)

ID:

First Name:

Policy HolderResponsible Party

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Section 2

Full Time Part Time Retired

Section 3

Address 2:

State / Zip:

Sex: Marital Status: Married Single Divorced Separated Widowed

E-mail: I would like to receive correspondences via e-mail.

Address:

City:

MaleOther

Female

Birth Date:

Full Time Part Time

Employment Status:

Student Status:

Medicaid ID: Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg.:

Name of Insured: Self Spouse Child Other

First Name:

Address 2:

First Name:

Address:

Home Phone:

Birth Date: Drivers Lic:Soc Sec:

Work Phone: Ext: Cellular:

City, State, Zip: Pager:

Last Name: Middle Initial:Last Name:

Insured Soc. Sec: Insured Birth Date:

Secondary Insurance Information

Name of Insured: Self Spouse Child Other

Rem. Deduct: .00

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00 Rem. Deduct: .00

Soc. Sec:Age: Drivers Lic:

Chart ID:

Home Phone: Work Phone:

Pager:

Ext: Cellular:

Last Name: Middle Initial:

Patient Is:

Relationship to Insured:

Relationship to Insured:

Preferred Name:

Patient Registration

TIME 10:39 AM DATE 6/22/2012

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date _____________________________________

Johnson Dental

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

Yes No

Are you allergic to any of the following?

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 ______________________

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 may

following questions.have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

If yes, please explain:Are you under a physician's care now? Yes No

Have you ever had a serious head or neck injury?Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Yes No If yes, please explain:Yes No If yes, please explain:Yes No If yes, please explain:

Comments:

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions

HerpesAnemiaAngina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

RheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStroke

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Rheumatic FeverRenal Dialysis

Radiation TreatmentsRecent Weight Loss

Yes NoYes NoYes No

Hepatitis B or C

High Blood Pressure

Yes NoYes NoYes NoYes No

HemophiliaHepatitis A

Pain in Jaw JointsParathyroid DiseasePsychiatric Care

Yes NoYes NoYes No

Hives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve Prolapse

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Swelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Other

Aspirin

If yes, please explain:

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you

Are you on a special diet? Yes NoDo you use tobacco? Yes No

Do you use controlled substances? Yes No

Yes No

Have you ever been hospitalized or had a major operation?

Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? Yes No

Yes No

Metal Latex Sulfa drugsPenicillin Codeine Local Anesthetics Acrylic

High Cholesterol

Osteoporosis Yes No

Medical History

Adult Dental History

Child Dental & Medical History

Patient Name: ___________________________________

Date of birth: ____________________

Dental History What is the reason for today’s visit? _____________________________________________________________________

Is this your child’s �rst visit to the dentist? Yes No

If no, date of last visit: __________________________ Date of last dental x-rays: _________________________

Was it a good experience? Yes No

Name of previous dentist:__________________________________ Phone: _____________________________

How would you describe your child? Relaxed Shy Outgoing Inquisitive Frightened Apprehensive

Oral hygiene habits

Yes No Does your child brush daily? # of times per day: _________

Yes No Does an adult assist with brushing?

Yes No Does your child �oss? # of times per week: _________

Yes No Does an adult assist with �ossing?

Yes No Does your child receive �uoride in any of the following forms?

Water supply Dentist Toothpaste Vitamins Tablets/drops Other_________________

Check if your child has or has had any of the following mouth habits or conditions:

Bad breath Fingernail biting Paci�er use Mouth breathing

Bleeding gums Finger sucking Loose teeth or broken �llings Jaw pain or tenderness

Blisters on lips Thumb sucking Gums swollen or tender mouth Sensitivity to (please circle)

Dry mouth Lip sucking Grinding teeth Cold / Hot / Sweets

Diet

Yes No Does your child need a bottle or something to drink to go to sleep?

Yes No Does your child wake up at night and eat or drink?

Yes No Do you give your child something to eat or drink after brushing their teeth at night?

____________ How many snacks does your child eat each day? (Juice alone counts as a snack.)

____________ How much soda does your child drink each day?

Yes No Does your child drink any beverage from a cup / sippy cup / bottle throughout the day?

CONTINUED ON BACK OF PAGE

Medical alerts (for staff use only)

Child Dental History

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have been offered and able to read a copy of Johnson Dental’s Notice of Privacy Practices.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

I understand by signing this form I will consent to your use and disclosure of my protected health

information to carry out treatment, payment activities, and healthcare operations. Your office

will continue to use my health information in some of these ways: by calling me by first and last

name from your waiting room, by mailing reminder appointment cards with reason for visit, by

reminding patients needing a pre-medication on reminder cards or confirmation calls, by calling

to confirm appointments, and internal audits of patient charts for practice evaluation purposes

as described in our Notice of Privacy Practices. I have the right to request alternative means of

delivery.

I am signing as a parent/guardian for _____________________________

Patient’s name

_____________________________________ _________________________________________ ___________

Print name Signature Date

_______________________________Staff Use Only_________________________________

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,

but acknowledgement could not be obtained because:

_____Individual refused to sign this acknowledgement. Date: ___________________

_____Communication barriers prohibited obtaining acknowledgement.

_____Emergency situation prevented us from obtaining acknowledgement.

_____Other ***Scanned Copy Serves as an Original***

Expectations

Whitening is effective for most patients and has been proven to be safe when done properly. The length of treatment ranges from a minimum of 2 weeks up to 4-8 weeks or more for patients with darker teeth. The degree of whitening you obtain during the procedure is dependent on four factors:

1. The length of time in each 24-hour period the tray is worn (a session). 2. The number of sessions the tray is worn. 3. The susceptibility of your teeth and/or internal colors to the whitening agent. 4. Habits you have that discolor teeth, such as smoking or the consumption of coffee, tea,

tomato sauce, red wine, etc. Crowns, bridges, veneers, partial dentures, and white fillings will not whiten with this treatment.

Directions for whitening your teeth

1. Before inserting trays, brush and floss your teeth thoroughly. 2. Ensure that your trays are dry. Express a small amount of whitening gel into the deepest,

outermost portions of the trays. A large amount is not needed. 3. Seat the trays completely onto the teeth. 4. Gently press the tray with a clean finger to adapt the soft tray material against the teeth

on the inside (tongue) and the outside (lip) edges of the tooth/gum area. Use caution since pressing too firmly will express too much gel out of the tray.

5. Wipe off excess gel with a clean finger or cotton swab. 6. Do not disturb the trays when wearing by lifting with tongue, fingers, etc. Take care not

to bite with pressure on the tray. This may cause excess solution to sit on the gum tissue, which can result in a tissue burn.

7. It is best to wear the trays overnight while sleeping (8-10 hours). This can be modified if you are experiencing more pain than you can handle or if you cannot tolerate wearing the trays while sleeping. Trays can be worn for 4 hours during the day OR can be worn every other night or day. If you do this, your treatment time will be lengthened, but you can still achieve the same results.

8. Remove the trays after wearing for the appropriate amount of time. Brush teeth thoroughly with toothpaste. Rinse twice; do not swallow rinsed gel. Brush tray gently with soft brush and rinse with cool water. Store trays in their case when not in use, but be sure they dry thoroughly so they are ready to be used for the next session.

9. After you are done whitening, you will need to touch up your whitening periodically (usually 1-3 times per year, depending on your eating habits). By touching up, you will be able to maintain your beautiful, white smile for years to come.

Possible side effects

Many times patients will experience increased sensitivity to cold during treatment. Some patients have reported temporary discomfort during whitening, such as gum and/or tooth sensitivity, tongue and lip soreness, or moderate, continuous teeth pain. Acidic, citric foods may increase sensitivity temporarily. Tips to reduce discomfort include:

1. Prevident (a high-fluoride prescription toothpaste sold at Johnson Dental) can be used

daily for at least 2 weeks before whitening is started, and also throughout the duration of the whitening process.

2. Ibuprofen or Tylenol can be used to reduce acute pain that can be associated with whitening.

3. If sensitivity becomes too uncomfortable, or if the trays cannot be tolerated at night, trays can be worn for 4 hours during the day. This will lengthen the total whitening time, but you will get the same great results.

If any of these symptoms occur and the above tips do not work for you and your pain is more than mild or persistent, or if you have any questions or concerns, call us at 507.645.9669. These side effects almost always resolve in 1-3 days after interruption or completion of treatment.

Precautions

1. Avoid dark foods or drinks that may restain your teeth for 24 hours after whitening. Examples of foods that can stain are coffee, tea, red wine, tomato sauce, tobacco, and dark berries.

2. Do not eat with your whitening trays in your mouth. 3. Keep and store the whitening agent out of heat or direct sunlight at all times to keep the

whitening agent from chemically breaking down. Store unopened tubes in the refrigerator, but keep the tube you are using at room temperature to help decrease sensitivity.

4. Keep your whitening solution away from small children and pets. 5. NEVER use any household or commercial whitening agents in your mouth!

Whitening gel active ingredients

1. 10% carbamide peroxide: whitens teeth 2. Potassium nitrate: decreases sensitivity 3. Fluoride: strengthens enamel

Scheduling for crowns and fillings

Restorative procedures (fillings and crowns) can be scheduled 2 weeks after the last session of whitening is completed. This is necessary for shade normalization and optimal bonding.

All instructions and information are also available on our website Johnson-Dental.com