Dental Patient Registration

Smile Mobile

Dental Patient Registration

Today’s Date:
Patient First Name Middle Initial Last Name / Social Security Number / Birth Date
____/____/_____ / Age / Sex
M F
Street Address: / City / State / Zip Code
Mailing Address ○ Same as Above / Parent /Guardian Email Address
Contact Phone Number (Please list all so that we may discuss treatment plan) / Preferred Pharmacy
Parent/Guardian Information Date of Birth
Name: / Address ○ Same as Above
Emergency Contact Name and Relationship to Child / Emergency Contact Phone Number

Please check if student needs assistance: ○ Vision○ Hearing ○ Reading ○Language other than English

Primary Dental Insurance
Please send copy of card. / Subscriber’s Name / Subscriber’s Social Security Number
Policy Number / Group # / Subscriber’s Birthdate

The above information istrue tothe best of my knowledge. I authorize assignment ofbenefitsforservicesreceivedto be paiddirectly toYourCommunity Health Center. I understandthatIam financially responsible for anybalance. I also authorizeYourCommunity Health Centerormy insurancecompany torelease any information required to process myclaims.

Signature:Date:

RECEIPTFORPRIVACYSTATEMENT: Wearecommittedtoprotectingyourpersonalhealthinformationincompliancewiththelaw.Bysigningbelowyou areacknowledgingthatyouhavereadtheYCHCprivacystatementandunderstandthatupon request,you mayobtain acopyofthe YCHCStatementofPrivacyPractices.

Signed:______Date: ______

Ethnicity / Education / May we text you?
Hispanic or Latino / Current Student? / Yes
Not Hispanic / Full Time / No
Not Reported /Refused to Repot / Part Time
Race / Highest Level of Education
Asian / Not yet in school / Number to Text:
Native Hawaiian / Pre-School Kindergarten
Other Pacific Islander / Grade School
Black/African American / Middle School
American Indian/ Alaska Native / High School / Alternate Number:
White (not Hispanic or Latino) / High School Degree/ GED
More than one race / Did not complete High School
Not Reported / Refuse to Report / Technical Trade School
Primary Language / College / Homeless?
English / College Graduate / Yes
Spanish / No
Russian
Ukrainian
Other
Please Specify:
How did you hear about us? / YCHC is my primary medical home?
Newspaper/TV/Radio Ad / Yes
Website / No
Special Event
Employee / I am using YCHC today for an urgent care need?
Other Organization / Yes
Friend / No
Other
PERSON(S) WHO MAY ACCOMPANY MINOR & MAKE DECISIONS FOR MEDICAL/DENTAL/ BEHAVIORAL TREATMENT
Name: / Relationship: / Phone:
1.
2.
3.
PERSON(S) WHO MAY OBTAIN MY HEALTH INFORMATION FROM YCHC
Name: / Relationship: / Phone:
1.
2.

How would you rate your child’shealth? ExcellentGood FairPoor

Is child currently under the care of a physician other than for routine care for the past six months? Yes No

If yes, for what condition:______

Has your child been hospitalized in the past year? Yes No

If yes, please explain: ______When?______For how long?______

Name of your physician: ______Phone: ( _____ ) _____ - ______

Address: ______Date of last complete exam? ___/___/___

______

•Is your child allergic to, orhad a bad reaction to any of the following? Yes No

Aspirin
Erythromycin
Clindomycin
Z-Pack (Zithromycin)
Biazin (Clarithromycin)
Topical Anesthetic / Tylenol
Tetracycline
Doxycyline
Minocycline
Local Anesthetic
Penicillin / Amoxicillin
Augmentin
Ampicillin
Latex
Keflex
Ceclor / Cephalexin
Codeine
Metal
Sulfa Drug

•Are you aware of your child being allergic to any other medication or substance? Yes NoIf yes, please explain:

______

•Please list any medications your child is currently taking including over-the counter medication:

______

•Has your child been given or have taken or taking any of the following medications?

FosamaxActonelBonivaBonefosArediaZometa

(Alendronate)(Risedronate)(Ibandronate)(Clodronate)(Pamidronate)(Zoledronic Acid)

•Are you currently taking, or previously taken Fen-Phen or Redux? Yes No If yes, how often or when did you quit? __

•Were you ever told you need to take antibiotics (pre-medicate) before dental treatment? Yes No

______

•Please check any of the following that your child has had or have at present:

Skin Issues
Lupus
Head-Neck
Eyes
Ear-Nose throat
Sinus Trouble
Respiratory
Asthma
Emphysema
Tuberculosis
Cardio Vascular
Mitral Valve Prolapse
Artificial Heart Valve
Rheumatic or Scarlet Fever
Synthetic Vascular Heart Graft
Infectious Endocarditis
Neuro-surgical Shunts
Portacaval Shunts
Heart Murmur (Organic)
Heart Murmur (Func./Innocent)
Heart Failure or Disease
Heart Pacemaker
Congenital Heart Lesion
Heart Surgery / Endocrine
Thyroid Disease
Diabetes
Liver Disease
Hepatitis A
Hepatitis B
Hepatitis C
Blood disease
Hemophilia
Leukemia
Sickle Cell Anemia
Abnormal Bleeding
Blood Transfusion
Bruise Easily
Allergy
Seasonal
Food
Other:
AIDS
Alzheimer’s
Arthritis
Artificial Joints (hip, knee, etc.)
Cancer
Chemotherapy / Chlamydia
Drug Addiction
Epilepsy or Seizures
Fainting or Dizziness
Fever Blisters
Genital Warts
Gonorrhea
Hemodialysis Patient w/ Fistula
or Shunt
High Blood Pressure
HIV Positive
Hyperactivity
Joint Replacement
Kidney Trouble
Mental Retardation
Psychiatric Treatment
Radiation Treatment
Speech Problems
Stroke
Syphilis
Valve Replacement
Yeast infections
Yellow Jaundice

Does child have any disease, condition or problem not listed above that we should know about? If yes, please list: ______

•HAS YOUR CHILD HAD A SERIOUS HEAD TRAUMA? Yes No If yes, please explain:______

•CHILD SUBJECT TO PROLONGED BLEEDING? Yes No

•FOR WOMEN ONLY:

Are you taking birth control pills? Yes No

Are you pregnant or trying to become pregnant? Yes No

Dental Concerns – Reason for Visit

Pain Bleeding gumsLost filingMissing teethCleaning/Exam Other:______

Feelings about seeing dentist today:

Negative (pain, anxiety)Normal (some anxiety) Positive (no anxiety)

# of months since last visit: ______What procedure was done:______

Dental History

Doeschild use:Tobacco Alcohol  CaffeineRecreational drugs

If yes, frequency: ______

# of “sugared” drinks/day (juice, soft drinks, etc.):_____

# of “diet’ drinks/day:_____

Other refined carbohydrates/day: _____

Family History

Any history of immediatefamily with heart disease, lung diseases, diabetes, etc?______

If yes, what family member?______

Age and health of: Mother:______if deceased, cause: ______

Father:______if deceased, cause: ______

Does either parent have dentures? Mother Father

Past Dental Treatment

Fillings Crowns Extraction(s) DenturesRoot Canal(s)Braces Implant(s)

Other: ______

Current Oral Hygiene Practices (frequency and type)

Frequency of brushing ______Type of toothbrush and toothpaste:______

Frequency of flossing ______Mouth rinse:______

Frequency of cleaning/check-ups:______

Other:______

Smile Mobile

Dental Consent to Treat Patient without Parent/Legal Guardian Present

Authorization

I have the legal right to preauthorize Your Community Health Center’s Smile Mobile and its personnel to deliver routine dental treatment and services to my child. Routine dental care may include, but is not limited to: dental examination, prophylaxis (cleaning), fluoride treatment, x-rays, sealants, and the creation of a treatment plan.

I, ______(please print parent/guardian name) request and authorize Youth Community Health and its personnel to deliver routine dental care to my child listed below as may be deemed necessary or advisable in the diagnosis and treatment of the minor child:

Child’s name: ______Date of birth: ______

Limitations

Identify any specific limitations on the kinds of dental services/treatments for which this authorization is given:

______

I affirm that I am either:The parent of the minor child in my legal custody; or a minor who has been lawfully married; or a minor parent or legal custodian of the minor child; or an adult standing in loco parentis, whether serving formally or not, for the minor charge in case of emergency as defined in section 431.063 RSMo; or a guardian of the minor for his ward; or a relative caregiver of the minor child as provided for in section 431.058 RSMo; or an adult eighteen years or older for myself.

______

Parent/Legal Guardian Name (print)Relationship to patient

______

Parent/Legal Guardian Signature Current Date

______

Contact phone number(s)

Treatment will require signatures on Consent Form on the next two pages.

This consent form will remain in effect for the 2016-2017 school year

Smile Mobile Consent Form 2016-2017

Student Name: ______

Informed Consent for Composite

(Tooth-colored) Fillings

I understand that the treatment of dentition (teeth) involving the placement of composite, resin fillings which may be more aesthetic in appearance than some of the conventional materials that have been traditionally used (such as amalgam or gold),may entail certain risks. There is a possibility of failure to achieve the desired or expected results. I agree to assume those risks that may occur, even if care and diligence is exercised by YCHC Smile Mobile dentist, in rendering treatment. These risks include possible unsuccessful results and/or failure of the filling associated with, but not limited to the following: Sensitivity, Risk of Fracture; Necessity for Root Canal Therapy; Possible need to perform direct or indirect Pulp Cap; Injury to the Nerves; Tooth coloration that may not exactly match tooth color and color that may change over time; Breakage, Dislodgement, or Bond Failure.

Informed Consent

I understand that it is my responsibility to notify YCHC dentist should any undue or unexpected problems occur, or if I experience any problems related to the treatment rendered, or the services performed. I have been given the opportunity to ask any questions regarding the nature and purpose of composite fillings, and have received answers to my satisfaction. I voluntarily assume any and all possible risks, including the risk of substantial harm, if any, that may be associated with any phase of this treatment in hopes of obtaining the desired outcome. By signing this document, I authorize YCHC Smile Mobile dentist and/or her associates to render any services deemed necessary or advisable in the treatment of my dental condition, including prescribing and the administration of any medically necessary anesthetic agents and/or medications.

I affirm that I am either:The parent of the minor child in my legal custody; orA minor who has been lawfully married; orA minor parent or legal custodian of the minor child; orAn adult standing in loco parentis, whether serving formally or not, for the minor charge in case of emergency as defined in section 431.063 RSMo; orA guardian of the minor for his ward; orA relative caregiver of the minor child as provided for in section 431.058 RSMo; orAn adult eighteen years or older for myself.

______

Parent or Guardian SignatureDate

______

Reviewed byDate

Informed Consent for Extraction

(Removal of Tooth)

I understand that there may be alternatives to the extraction of teeth. After reviewing the various options presented to me by the dentist with Your Community Health Center, I have agreed to allow theextraction of tooth/teeth that need to be removed. I understand that there are various normal complications that can occur despite all efforts to the contrary as a result of the extraction(s) which include, but are not limited to:Dry Socket; Infection bleeding and/or bruising which may be prolonged; Swelling; Injury to adjacent teeth or fillings; Unusual reaction to medications given or prescribed; Sinus involvement, which may require surgical repair; Injury to the nerves of the lower lip and tongue causing numbness, which could possibly be permanent; Pain or injury of the temporomandibular joint (TMJ), including broken jaw.

I understand that a perfect result cannot be promised, or guaranteed. If any unforeseen conditions arise during the procedure, I request and authorize YCHC dentist to do whatever he/she deems advisable to correct the condition.

Smile Mobile Consent Form 2016-2017

Student Name: ______

I affirm that I am either:The parent of the minor child in my legal custody; orA minor who has been lawfully married; orA minor parent or legal custodian of the minor child; or an adult standing in loco parentis, whether serving formally or not, for the minor charge in case of emergency as defined in section 431.063 RSMo; orA guardian of the minor for his ward; orA relative caregiver of the minor child as provided for in section 431.058 RSMo; orAn adult eighteen years or older for myself.

______

Parent or Guardian SignatureDate

______

Reviewed byDate

Consent for Nitrous Oxide

(Laughing Gas)

Nitrous Oxide/Oxygen Inhalation is a mild form of conscious sedation used to calm an anxious patient. It is a colorless, odorless gas that is administered through a small mask placed over the nose. Oxygen is used after the procedure to flush the nitrous oxide out of the patient’s system and minimize the effects of the gas.

Benefits of Nitrous Oxide: Relief of Anxiety; Pain Control; Relief of Gagging; Reduction of Overall Stress

Nitrous Oxide Risks:Nausea and Vomiting; Excessive Perspiration; Temporary Inability to Perceive One’s Spatial Orientation; Numbness and/or Tingling

Acknowledgement

I acknowledge that all questions I have asked concerning Nitrous Oxide have been answered to my satisfaction.I understand the information that has been provided to me and wish for my child/myself to receive Nitrous Oxide.

I have provided as accurate and complete a medical and personal history as possible, including antibiotics, drugs, herbal supplements, or other medications (prescription or non-prescription) I am currently taking as well as those to which I am allergic.

______

Parent or Guardian SignatureDate

______

Reviewed byDate

PatientRightResponsibilities

AsapatientofYour CommunityHealth Center,orastheparentor guardian of aminorpatient,we wantyoutoknow your rights.

AsaPatient,youhavethe rightto:

Receivehealthcarethatrespectsyourcultural,psychosocial,andpersonalvaluesandbeliefs.
Requestacopyof anyrulesor regulationsthatrelatetothe conductofpatients,asprovidedbelow.
Knowyourrecordsand communicationsareconfidentialtothe extentprovidedbylaw,andtoexpectprivacyduringmedicaltreatmentandcare.
Participateinany considerationof ethical issuesthat ariseinyouror yourchild’s care.
Refusetobeexaminedortreatedbymedical studentsorotherclinical staff,withoutjeopardizingaccesstomedicalcareand/ortreatment.
Refusetoserveasaresearchsubjectorreceiveanycareorexaminationthatisprimarilyforeducationalorinformationalpurposes.
Inquireof anyrelationship the clinic,oryourphysician,haswithanother health-carefacilityoreducationalinstitution,totheextent that therelationship relatestoyouror yourchild’scare.
Receiveinformationregardingfinancialassistance.
Obtainthenameandspecialtyofthephysicianorotherhealth-careproviderscaringfor youoryour child.
Haveallreasonablerequestsrespondedtopromptlyandadequatelywithincliniccapacity.Pleaseallowatleast48hoursforprescriptionrefillrequests.
Receivesufficientinformationtogiveinformedconsenttotreatment,totheextentprovidedbylaw,includinganexplanation ofyouror your child’s condition,proposed treatments,andalternativetherapies,withtheirrespectivebenefitsandrisks.
Makedecisionsregardingyourhealthcare, includingthedecisiontorefuseordiscontinuetreatment,totheextentpermittedbylaw.
Filloutadvancecaredirectives,suchasahealthcareproxyformtodesignate someonetomakedecisionsforyou,intheeventthatyoubecomeincapable ofunderstandingaproposedtreatmentorprocedure,orareunabletocommunicateyourwishesregardingyourcare.
Aproperassessmentandmanagementofpainand/ordiscomfort.
Receiveprompt,life-savingtreatmentinanemergencywithoutdiscriminationordelaybasedoneconomicorpaymentconcerns.
Receiveanitemizedstatementanddetailedexplanationof yourbill.
Registercomplaints,seeksolutionstoproblems,orfilegrievancewiththeclinicifyouhaveconcernsregardingyourcare.
PrimaryCareServicesregardlessofabilitytopay.

Thecareyoureceiveispartiallydependentuponyou cooperatingwithyourhealthcareproviders,includingcommunicatingopenlyandhonestly,followingtreatmentplans,andrespectingthefacilitystandardsofconduct.

AsapatientatYourCommunityHealthCenter,you areresponsiblefor:

Followingallfacilityrulesasposted insideand/oroutsidetheclinicalfacility.Respectingandconsideringotherpeople,employees,thepropertyofothers,andpropertyofYourCommunityHealthCenter.
Advisingusofanychangesinthefollowing:Name,Address,PhoneNumber(s),InsuranceInformation,Income, and FamilySize.
Providingaccurateandcompleteinformationaboutcurrentsymptoms,medicalhistory,hospitalizations,medications,careobtainedoutsidethepractice,self-careinformation,advancedirectives,andanyothermattersrelatedtocare.
Followinginstructionsthat youand yourcareteam haveagreed upon.Followingthroughon goalsforself-managementofyourhealth.
Askingquestionsaboutyour carethatyoumaynotunderstandorhavequestionsabout,includingrisksofprocedures,outcomes,andcostsoftreatment.
Knowingwhatmedicationsordrugsyouaretaking,whyyouaretakingthem,andtheproperwaytotakethemaccordingtoyourprovider’sinstructions.
Keepingscheduledappointments,arrivingontimeforscheduledappointments,andforcallingatleast 4hoursin advanceto cancelwhenyoucannotkeep ascheduledappointment.YCHCreservestherighttoterminateservicetopatientswhodonotshowforappointmentsmorethanthreetimes in a12month period.
Attendingandsupervisingyour children whileinthefacility.
Callingyourpharmacytorequestarefill1 weekbeforeyourunoutofyourprescription.Ifauthorizedbyan YCHCprovider,yourrequestwillbefilled within72businesshours.
Payingbillsandfeespromptly asdefinedinthefinancialpolicies.

IhavereadandunderstandtheYourCommunityHealthCenterPatientRightsandResponsibilitiesandhavebeen given anopportunitytoobtain acopyformypersonal records.

Parent/ Guardian SignatureDate

SlidingFeeInformation

ThankyouforselectingYourCommunityHealth Center.Partofour mission for YCHCistoprovidequalityservicesto you and yourfamily.In doingso, YCHCoffersaslidingfee adjustmentforpatients andmembersoftheirfamilies(asdefinedbelow)whofallbelow200%ofthe povertyguidelinesassetforthby theFederalGovernment.Incomelevels are basedon total “family”income,family is definedbelow.Theamount of the discount and theincomeranges for those discountsaresetby YCHC’s Board ofDirectorsandapprovedbytheFederalGovernment.Incomeguidelinesarerevisedannually.Currentdiscountsandincomeguidelinesareavailable at YourCommunityHealthCenter.

Theslidingfeeapplicationwillcoverallmedicallynecessarymedical,behavioral,anddentalservices.Thecostsofprocedures,labs,tests,andprovidervisitsthataredeemedmedicallynecessarywillqualifyfortheslidingfeediscount.Thecostsofprocedures,labs,testsandprovidervisitsthataredeemedoptional,cosmeticorexperimentalwillbetheresponsibilityofthepatientrequestingtheservicesat100%oftheregularratecharged.Evenifservicesareorderedbyaprovider,itdoesnotnecessarilymeanthattheyaremedicallynecessary.

Definitions

Family-Afamilymeansthosepersonswithinthesamehousehold(includingdependents/partner)who areapplyingfortheslidingfeediscountusingtheir combined income.

Individual-Anindividual is aperson18yearsoldor over who hasverifiableincomeusingthe listbelow(*).

IncomeVerification

Income is verified once ayear.Ifapatienthasachangeintheir income,itistheirresponsibilitytonotifyYCHCofthatchange.YCHCreservesthe righttoverifyincome with an employer atanytime.(*)Patientsarerequestedtoprovideatleasttwoofthefollowingitemsasverificationofincome.

● Previousyeartaxreturn ● PreviousyearW-2form(s)

● Lay-offnotificationfromlastemployer● Currentpaystubs(last4weeks,if possible)

● PayStubsfromunemployment (last 4,ifpossible)● Currentinformationfromunemploymentoffice

Ifyou werenotrequired tofileprior’syears incometaxreturn oryoureceive anyof the followingtypesofincome,documentationmustbesubmittedshowingtheamountsofeachreceivedbyanymemberofthehousehold.

● ChildSupport● WelfareAssistance● SocialSecurity● Unemployment

● Self-EmploymentIncome● RetirementIncome● Alimony● Worker’sCompensation

● DisabilityIncome● AnyOtherIncome● FoodStamps

EligibleFees

Medical,MentalHealthandDentalServicesthatareprovided at YCHCareeligibleforthesliding feediscounts.Previouscharges,OWIassessments,electiveproceduresandoutsideservicesarenoteligibleforaslidingfeediscount.Deductiblesareeligibleforslidingfeediscounts.

MinimumCharge

Thereisaminimummedical, mentalhealth anddentalchargeforallslidingfeevisits,asapprovedbytheYCHCBoardofDirectors.The minimumchargemustbepaidatthetimeofservice regardlessofinsurancecoverage.

AdditionalInformation

Paymentisrequiredwhenservicesarerendered.Timelinessincompletingthisapplicationisimportant. Yourapplicationfortheslidingfeediscountwillnotbeapproveduntilcompletedocumentationisreceived. Untilyouareapprovedforaslidingfeediscount,youwillbe responsibleforthefullchargesassociatedwith servicesyou receivefromYCHCunlessanyamountsarecoveredbyotherthirdpartyservices.If you have anyquestions, staffatYCHCwillassistyou.ThankYou!!

FamilySizeandIncome

Thisisimportantinformationforourfederalfunding

PatientName:

Instructions:Pleaseselectthe familysize inthefar left column. Thenpleasecircle

yourincome range to the rightofyourselectedfamily size (inthesamerow.)

SlidingFeeApplication

Patient’sName ______

HomeAddress: __

City:

State:

County:Zip: __

Sex: Female Male Dateof Birth:

SocialSecurityNo. ___

HomePhone:

WorkNo.:

MaritalStatusofPatient: SingleMarriedSeparatedDivorcedWidowedEmployer/School: Occupation: Employer’s Address:

Do you haveanyotherinsurance?Yes No Ifyes,what kind? Isyouremploymentseasonal?Yes No

Isyour employmentrelatedtoagriculture? Yes NoNumber ofpeopleinyour household? AreyoueligibleforMedicaid? Yes No

AnnualGrossIncome (alladult membersofhousehold)? $_FinanciallyResponsibleParty:

Name:Date of Birth: RelationshiptoPatient: SocialSecurityNo.: HomeAddress: City: State: Zip:

HomePhone:

CellPhone:_

FamilySize:(Ifadditionalspace isneeded,pleaseaddto backofpage)

NameDateofBirthRelationship

Income:

CurrentMonthlyLast 12MonthsTotal

WagesorSelfEmployment$ SocialSecurity/PublicAssistance$ Unemployment/WorkersComp $ Alimony/ChildSupport $ Pensions/RetirementIncome $ FoodStamps/WelfareAssistance $ DisabilityIncome $

AnyOtherIncome$

Ideclareunderpenaltyof perjury,underlawsoftheStateofMissouri,thatallstatementscontained inthisapplicationand accompanyingdocumentsaretrue andcorrect,withfullknowledgethatallstatementsmade inthisapplicationaresubjecttoinvestigation andthatanyfalseordishonest answertoanyquestionmaybegroundsfordenialof application.

Ihave readthe SlidingFee Application andIunderstandthatpaymentisdue atthetimeofservices.Ifdocumentationof income verificationisnotgiventoYCHCwithin30daysofthisapplication,theapplicationwill nolonger bevalidandyoumustreapply.Thankyouinadvance foryourcooperation.

Signature:

Date:

ForOffice Useonly:

Qualifiesfor:_%DiscountIneligibleDateofDetermination:

Signatureofpersonmakingeligibilitydetermination: