Portable Dental

Patient Information and Consent Form

Dear parents: The information requested is very important. In order for your child to receive dental care provided by Access Family Care staff, you will need to read this form carefully and complete both sides for your child. Please make your answers as complete and accurate as possible. This will help us provide the best possible dental care foryour child. This information form becomes part of our permanent record and will be held in strict confidence. Circle YES or NO, where indicated. Please contact your school nurse or Access Family Care at (417)451-9450with any questions you may have. Thank you!

Legal Name of Patient:______

First MI Last

Date of Birth:______Age:______Grade:______Gender: [] Male [] Female

Social Security #:______(this information is important, but if you do not feel comfortable placing your child’s SSN here,please call us at 417-540-4868,or leave a number you would like to be reached.______)

Ethnicity:Is the patient of Hispanic or Latino origin? [] Yes [] No Primary Language:______

Race: [] American Indian or Alaska Native [] Asian [] Black or African American [] Native Hawaiian or Pacific Islander

[]Multi-racial [] White [] Other

Home Address:______City: ______State:______Zip Code:______Phone Numbers: Home ______Other______

INSURANCE or MISSOURI HEALTH NET INFORMATION (please fill out entirely)

Name of Dental Insurance:______Employer:______

Name of PolicyHolder & DOB: ______Group #______

Policy#/Subscriber ID/ SSN:______Insurance Phone #______

Insurance Address ______

(Please feel free to include a copy of card)

Medicaid/MOHealthnet Number: ______(Please feel free to include a copy of card)

If no, MOHealthnet Rejection letter: Yes No (If Yes, please send copy of letter)

Has the patient seen a dentist before? Yes No *If yes, Date of last dental visit: ______

Please check all the reason(s) for seeking dental care for your child:

Routine Checkup ______First Visit ______Bleeding around teeth ______

Swelling of face ______Toothache ______Appearance of teeth ______

Accident to teeth ______Crowding of teeth ______Other (specify) ______

Dental and Medical History of the patient: (Please circle YES or NO where indicated)

  1. Has the patient had any unusual or unpleasant experiences in a dental or medical office?YesNo

2. Has the patient ever had any injuries to the face, mouth or teeth? YesNo

3. Has the patient ever had a toothache?YesNo

4. Does the patient have any oral habits such as thumb sucking, etc?YesNo

5. Is the patient presently in good health?YesNo

6. Is the patient presently under the care of a physician?YesNo

7. Has the patient been in the hospital or had surgery? YesNo

8. Is the patient’s immunization record up to date?YesNo

9. Any problems during pregnancy, deliveryor during the first year of the patient’s life?Yes No

10. Does the patient take any fluoride supplements?YesNo

11. Is the child taking any medications at this time?YesNo

If yes, please list ______

  1. Hasthe patient had any unusual reaction or allergy tomedication like Penicillin, aspirin,

or local anesthetics? If yes, please explain ______YesNo

13. Is the patient currently pregnant? If so, estimated due date? ______Yes No

Does the patient have a history of:

Excessive or prolonged bleeding Yes No Cerebral Palsy YesNo

Spina Bifida Yes No High Blood Pressure Yes No

Sickle cell disease or trait Yes No AIDS or HIV YesNo

Kidney Disease Yes No Liver disease Yes No

Rheumatic Fever Yes No Ear infections YesNo

Fainting Yes No High Fevers Yes No

Diabetes Yes No Tonsillitis Yes No

Tuberculosis (TB) Yes No Dizziness Yes No

Behavioral Problems Yes No Anemia Yes No

Cancer or Tumors Yes No Hepatitis Yes No

Hearing Problems Yes No Convulsions (seizures) Yes No

Birth Defects Yes No Vision Problems Yes No

*Heart murmur Yes No *Asthma Yes No

Is premedication required? Yes NoLast asthma attack? ______

Any special problems not listed above? ______

______

Consent and Agreement:

It is our policy to ensure that you are thoroughly informed of the treatment that we plan to provide and to obtain consent before any non-reversible dental treatmentis provided for your child. I understand there are some risks that are inherent in all dental procedures. I am aware that the risks are essentially the same as those procedures performed in a private dental office. Further, I certify that I understand and agree to the conditions set forth above. I also understand I am free to ask any questions regarding the procedure and risk involved.

I am hereby giving my consent to authorize the Access Family Care Dentist, and support staff involved, to render any services s/he deems necessary or advisable for treatment of my child’s dental condition. I understand services will be rendered on site of my child’s school facility, without a parent or guardian present.

Name of Parent/Legal Representative & Relationship to patient______

Signature ______Date______

This treatment consent will be in effect for the year of September 1, 2014 – May 31, 2015

*Administration: 417-451-9450 Fax: 417-451-9459.

*Joplin: Dental=417-782-0080 Medical= 417-782-6200

Anderson: Dental= 417-845-2273 Medical= 417-845-8300

Cassville Medical/Dental: 417-847-0057

Neosho Medical: 417-451-4447