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K64 Business Machinery & Equipment Credit Receipt R ELLIS COUNTY TREASURER Mike Dillinger P.O. Box 520 Hays, KS 676010520 Phone: (785× 6289465 Email: treasury Ellis.net Fax: (785× 6289467 JONES

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1. Start by gathering all the necessary information. You will need the personal details of Jones Jarrod E, including his full name, address, phone number, and email address.
2. Fill out the patient information section. This includes providing the patient's name, date of birth, social security number (if applicable), and insurance information. Make sure to double-check the accuracy of the information before proceeding.
3. Move on to the medical history section. Here, you will need to record any existing medical conditions, allergies, medications being taken, and past surgeries. It is important to be thorough and provide as much detail as possible to ensure proper dental care.
4. Proceed to the dental history section. This involves documenting any previous dental procedures, oral health concerns, and current symptoms or complaints. Include information about any ongoing dental treatments or orthodontic work.
5. Next, review and sign the consent and authorization forms. These forms typically cover consent for treatment, release of dental records, and compliance with privacy policies. Read each form carefully and ensure that you understand and agree to all the terms.
6. Finally, submit the completed form to the dental office. You can either hand it in personally or send it through mail or email, depending on the facility's preferred method. Make sure to keep a copy of the filled-out form for your own records.

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