PATIENT INFORMATION FORM

Welcome to Columbia Periodontal Associates

LOCATIONS: 3527 Bush River Rd. (803)798-0894 2325 Devine St. (803)-252-2844 575 Old Chapin Rd (803)-358-3021

J. Lee Ayers, Jr., DMD, MHS Mark L. McEntire, DMD, MHS Dustin C. Hedgpeth, DMD, MSD

Chart#: FOR OFFICE USE ONLY

Patient Name: Last First MI Preferred NameTitle: Mr/Ms/Mrs/etc Gender: Male Female Family Status: Married Single Child OtherBirth Date: Prev. Visit: Email Address: Phone: Home Mobile Work Ext Best time to call: Address: Address 1 Address 2 City --ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYState Zip Code

Patient SS# *

Patients Employer

Spouses Name

Spouses Employer

General Dentist:

Medical Physician

Date of last exam

Reason for your visit today?

Emergency Contact Person *

Emergency Contact # *

MEDICAL HISTORY

Last Name: *

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

*PREMED Acid Reflux / Ulcers agumentin Alergy Prevident Allergy- Adhesives Allergy- Darvon Allergy- Demerol Allergy- Keflex Allergy- Latex allergy sulfa allergy: statin drug Allergy-Amoxicillin Allergy-Aspirin Allergy-Codeine Allergy-Erythromycin Allergy-Local Anesth Allergy-Penicillin Allergy-Phenobarbito Allergy-Sulfa Drugs Allergy-Tetracycline Anemia Angina/Chest Pains Anti-Coagulants Anxiety Artifl Valves/Joints Asthma Blood Disorder Cancer Chemical Dependency Chemo / Radiation COPD Crohn's Disease Diabetes Diabetes-Insulin Dep Emphysema Epilepsy/Convulsions epinephrine Excessive Bleeding Fainting / Seizures Fibromyalgia Frequent Aspirin Use Handicapped-Mental Handicapped-Physical Heart Attack/Disease Heart Infection Heart Murmur Heart Surgery/Stent Hepatitis High Blood Pressure HIV / AIDS Positive Irritable Bowel Synd Joint Replacement Kidney Disease latex Liver Disease Minocycline MRSA / VRSA MVP NO Drugs NO Epinephrine NO Nitrous NO Novacaine Organ Transplant Pacemaker penicillin Phenobarbatol Pulmonary Disease Rheumatic Fever Stroke / TIAs Swollen Ankles Thyroid Problem Tuberculosis xOther - See Notes

If any conditions or alerts selected above need further clarification, please describe below.

WOMEN ONLY: Are you pregnant? Yes No

WOMEN ONLY: Do you take birth control pills or hormone pills? Yes No

Are you under the care of another physician? * Yes No

If yes, why?

Have you been hospitalized for any surgical operation or serious illness? * Yes No

If yes, when?

Are you taking any medications or supplements? If yes, please list: * Yes No

MEDICATIONS

Last Name: *

Have you taken or are you taking any Bisphosphonate drug used to treat osteoporosis or Paget's disease? Examples; Fosamax, Actonel, Boniva, Reclast, Didronel, Zometa etc. If yes, please list the drug and date taken. * Yes No

Do you have any other allergies not listed above (including allergies to medications)? If yes, please explain below * Yes No

ALLERGIES

Are you currently taking any blood thinners (this includes Asprin, Plavix, Coumadin)? If yes, please list: * Yes No

BLOOD THINNERS

Have you ever been instructed by a doctor to Pre-Medicate with antibiotics prior to going to the dentist due to a heart condition or joint replacement? If yes, please list drug and reason. * Yes No

PRE-MED

Are you currently using tobacco products? if yes, what and how often? * Yes No

TOBACCO USE

Do you drink Alcohol in excess or have you ever been treated for alcohol abuse? If yes, please explain * Yes No

ALCOHOL USE

Do you use recreational drugs or medications not prescribed by your physician? If yes, please explain * Yes No

OTHER DRUGS

Name of Person filling out this form *

Medical History Reviewed By:

Signature Date

Last Name: *

PERSON RESPONSIBLE FOR ACCOUNT

Person Responsible for Account SS# *

Person Responsible Date of Birth: *

DENTAL INSURANCE

Primary Dental Insurance

Name of Insured: Last First MI

Insured's Birth Date:

ID #: Group #:

Insured's Address: Address 1 Address 2

City --ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYState Zip Code

Insured's Employer Name:

Employer Address: Address 1 Address 2

City --ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYState Zip Code

Patient's relationship to insured: Self Spouse Child Other

Insurance Plan Name:

Insurance Address: Address 1 Address 2

City --ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYState Zip Code

Spouse/Partner's Date of Birth:

Insurance Company Phone Number

If you have Secondary Dental Insurance, please present your insurance card to the front desk at the time of your appointment.

Patient Name: Last First MI Preferred Name

SURGERY RESCHEDULE AND CANCELLATION POLICY

Due to the costs of surgery setup and time allotted for all surgery patients, there will be a charge of 20% of the actual surgery fee for any surgery appointment cancelled or rescheduled less than 48 hours in advance.***All cancellations must be made by phone. We cannot accept any cancellations sent by email, text or the answering service.

*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for Surgery Rescheduled and Cancelation Policy.

CONSENT TO TREAT

1. I authorize the performance of dental procedures explained as necessary to treat indicated periodontal or dental concerns. This treatment is to be performed by Dr. Ayers, Dr. McEntire, Dr. Hedgpeth and/or staff of Columbia Periodontal Associates. 2. I consent to the performance of procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions, which the above named doctor or his associates or assistants may consider necessary or advisable in the course of the procedure. 3. I consent to the administration of such anesthetics as may be considered necessary or advisable by the periodontist responsible for this service, with the exception of spinal or general anesthetics. 4. The nature, purpose, and benefits of the operation, possible alternative methods of treatment to include delay or refusal of surgery, the risks involved, the possible consequences, and the possibility of complications have been explained to me by Dr. Ayers, Dr. McEntire, Dr. Hedgpeth and/ or staff of Columbia Periodontal Associates.

6. I consent to the photographing of the operations or procedures to be performed, for medical, scientific, or educational purposed. 7. For the purpose of advancing medical education, I consent to the admittance of observation the operation room. 8. I understand that Columbia Periodontal Associates may ask for a blood draw for HIV/ Hepatitis testing if an employee is injured by a needle stick or exposure to body fluids.

*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for Consent to Treat.

AUTHORIZATION FOR RELEASE OF INFORMATION COMPOUND RELEASE AND ACKNOWLEDGEMENT OF NOTICE OF PRIVACY

I authorize the release of protected health information to Columbia Periodontal Associates * Yes No

Please list any person (s) (provide name and number) to whom you release authorizaton for Finacial and Medical information:

I authorized Columbia Periodontal Associates to leave voicemail * Yes No

I authorized Columbia Periodontal Associates to take photo or x-ray and send to insurance for insurance purposes only. * Yes No

I authorized Columbia Periodontal Associates to send me email * Yes No

I authorized Columbia Periodontal Associates to send me text * Yes No

* I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to reveive email and/or text communication if selected.

*PATIENT RIGHTS: I have right to revoke this authorzation at any time, I may inspect or copy the protected health information to be disclosed as describe in this document, revocation is not effected in cases where the information has already been disclosed but will be effected going forward, Information used or disclosed as a result of this authorization may be subjected to redisclosure by the recipient and may no longer be protected by federal state law and I have the right to refuse to sign this authorization and that my treatment will not be contioned on signing.

*I have read and reviewed the Notice of Privacy Practices on Columbia Periodontal Associates website under forms.

*By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature.