Treatment Consent And Medical Information Form printable pdf download

ADMIN. USE

SmileHealthy

ONLY:

Mobile Clinic

Present: _____

Treatment Consent and Medical Information Form

Absent: _____

PLEASE PRINT USING INK

SmileHealthy has arranged for dental services for you or a child under your care which may include an exam, cleaning, fluoride

treatment, sealants and in some cases restorative care. Licensed Dentists, Hygienists, and Assistants will perform at the clinic with

portable dental equipment. In addition you or the child may receive fillings, extractions and anesthetic based on the treatment

performed at a restorative clinic. You or the child may also receive x-rays.

☺ ☺ ☺ ☺ Patient’s Information

School/Site Name: _____________________________________

Grade/Classroom ______ A.M. P.M.

Name: _____________________________________________

Home Address: _______________________________________________________ Apt. # ___________

City: ___________________________ Zip: ________________ County: ________________________

Date of birth: _____/_____/_____ Sex: Male / Female Phone number: (_______)_______-__________

Race (check all that apply, for research purposes only, not required for eligibility):

Hispanic

Non-Hispanic

White

African American

Asian/Pacific Islander

American Indian/Alaskan Native

Other

Unknown

☺ ☺ ☺ ☺ Patient’s Insurance Information

Do you or the child qualify for and receive benefits from Medicaid, KidCare, AllKids, or Medical Card?

Yes / No

IF YOU CIRCLED “YES”, YOU MUST COMPLETE THE FOLLOWING:

9-Digit Number on Medicaid card : ___ ___ ___ ___ ___ ___ ___ ___ ___

Are you or the child covered by private dental insurance plan?

Yes / No

If you circled Yes, please provide:

Insurance Co. Address:______________________________________________________

Insurance Co. Name: _______________________

Group or Policy #:________________

Identification #:__________________

Employer Name: __________________________

Insurance Co. Phone: (_____) ________-_________

Name of Policy Holder: _________________________ Employer Phone: (_____)_______-___________

Policy Holder Birthdate:______________ Policy Holder’s Social Security Number: __ __ __ - __ __-__ __ __ __

☺ ☺ ☺ ☺ Patient’s Medical History

If you have no medical conditions, please initial here: _____________

Please check the box of any condition you or the child may have had or are currently suffering from:

Heart Murmur

Mitral Valve Prolapse

Artificial Heart Valve

Artificial Joints

Tuberculosis

Allergy to Latex/Colored Dyes

A.I.D.S./HIV Positive or Other

Rheumatic Fever

Blood Disorder

bb Asthma

Hepatitis A/B/C

Cardiac Surgery

Allergies

Epilepsy

Psychiatric Treatment

High/Low blood Pressure

Pregnant

Diabetes

Other medical conditions

Oral Contraceptives

If you checked any of the boxes, please explain: __________________________________________________

Please list any medications you or the child are taking: _____________________________________________

The above information is accurate and complete to the best of my knowledge and is only for use in treatment, billing and

processing of insurance for benefits for which I or the child I am caring for is entitled. I authorize the dentists to release

any information, including the diagnosis and the records of any treatment or examination rendered to me or the child

during the period of such dental care, to third party payers and/or other health practitioners. I authorize my insurance

company to pay directly to the dental office the benefits otherwise payable to me. If no current public or private dental

insurance plan is made available to the provider, I understand that I may be billed for the services provided. Patients

without insurance will be charged for care but may be eligible for grant support. I also give permission for dental

providers and representatives of the Illinois Department of Public Health to return to recheck dental sealants. By signing

below, I acknowledge that I have read and understand this authorization as it pertains to me or a child in my care and have

read and understand the HIPPA policy regarding myself or a child in my care.

Printed Name: __________________________ Signature: _______________________________ Date: __________

Treatment Consent And Medical Information Form

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