Download Adult Dental Patient (English) - Treasure Coast Community Health

Date: _________________________
Adult Dental Registration
1. Social Security:
2.
3.
4.
5.
6.
7.
8.
-
Name (First and Last):
Mailing Address:
Apartment:
Home Phone:
Email address:
Preferred phone:
Gender:  Female 
-
Date of Birth:
/
/________
M.I.
City/State:
Zip Code:
Work Phone:
Cell Phone:
Preferred contact method: Voice
Text
Email
Male
9. Gender Identity:
 Male

 Female
 Transgender Male/Female to Male
Transgender Female/Male to Female
 Other

Chose not to disclose
10. Sexual Orientation:
 Straight
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
 Gay
 Lesbian
 Bisexual  Other
 Decline
Martial Status:  Single
 Married
 Divorced  Widowed  Legally Separated
Are you signed up for our patient portal?  Yes
 No
Do you consider yourself to be Hispanic?  Yes
 No
Race (Please check one):
 Asian
 Native Hawaiian
 Other Pacific Islander
 Black/African American  American Indian/Alaska Native  White
 More than one race
What language are you best served in:
 English
 Spanish  Creole
 Sign Language
 Other
Employment Status*:
 Unemployed
 Employed
 Self-employed
 Disabled
 Retired
 Part Time Student  Full Time Student
Emergency Contact Name:
Phone:
Relationship to Emergency contact:
Preferred Pharmacy:
Mother’s maiden (last) name:
How did you hear about TCCH?
In the past two years or prior to retirement or disability have you or your head household worked in agriculture?
 Yes
 No
As a Federally Qualified Health Center we are required to ask your approximate Monthly Income (before taxes):
_____________
Number of people supported in household:
Do you have any type of insurance?  Yes
 No
If yes, primary insurance name:
ID#:
Secondary insurance name:
ID#:
Are you homeless**?  Yes  No
If yes, choose one of the following: Shelter Transitional Doubling Up Street Other
Do you live in Section 8 Public Housing?
 Yes  No
Are you a military veteran?
 Yes  No
*Employment Status:
Employed – You earn a living either working part-time or full-time for another individual, company or organization.
Self-employed – You earn a living working from your own business and not earn salary or commission from another individual.
Disabled – You receive monthly payments from the government for a disability
Retired – You have retired from working and receive a social security check monthly
Full-time/Part-time Student – You are enrolled in an accredited school on either a part-time (<12 credit hrs) or full-time (12 credit hrs or
more).
**Homeless Status:
Shelter – You are living in an organized shelter for homeless persons.
Transitional Housing – You are residing in a small unit that helps a person transition from homelessness to permanent housing.
Double Up – You are living with other individuals in their home and/or apartment who are not financially responsible for you.
Street – You are living outdoors, in a car, in an encampment (tent city), in a makeshift
housing/shelter. Other – You are living in a single room occupancy hotel or motel or other day-today paid for housing.
TCCH #1002 Effective 1.17
PATIENT CONSENTS AND ACKNOWLEDGEMENTS
INITIAL
I.
Consent for Treatment
I hereby give consent and authorize treatment at Treasure Coast Community Health Center, Inc. for myself,
the patient.
II.
Consent for Treatment of a Minor
I, as the parent or legal guardian of the patient, do hereby give my consent and authorize treatment.
Furthermore, I grant permission for
to authorize Medical
Treatment in my absence.
III.
Medical Students
I understand that Treasure Coast Community Health Center, Inc. supports the education ofmedicall
professionals and maintains Medical Students that may assist in relation to care.
IV.
Notice of Privacy Practices
I acknowledge that I have been offered and/or received thepractice’s Notice of Privacy which describes the ways in
which the practice may use and disclose my healthcare information for its treatment and payment/healthcare
operations and other described and permitted uses and disclosures. I understand that I may contact the
Compliance Officer if I have a question or complaint. To the extent permitted by law, I consent to the use and
disclosure of my information for the purposes described in the practice’s Notice of Privacy.
V.
Release of Information
•
Healthcare information may be released to any person or entity liable for payment on the patient’s behalf
in order to verify coverage or payment questions or for any other purpose related to benefit payment.
•
If I am covered by Medicaid or Medicare, I authorize the release of healthcare information to the Social
Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the
appropriate state agency for payment of a Medicaid claim. This information may include, without limitation,
historyand physical, emergency records, laboratory reports, drug and alcohol treatment and discharge
summary.
• Federal and state laws may permit this facility to participate in organizations with other healthcare
providers, insurers, and/or other health care industry participants and their subcontractors in order for these
individuals and entities to share my health information with one another to accomplish goals that may
include but not limited to: improving the accuracy and increasing the availability of my health records;
decreasing the time needed to access my information; aggregating and comparing my information for
quality improvement purposes; and such other purposes as may be permitted by law. I understand that this
facility may be a member of such organizations. This consent specifically includes information
concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic
information, chemical dependency conditionsand/or infectious diseases including, but not limited to, blood
borne diseases such as HIV and AIDS.
I hereby permit the practice and the physicians or other health professionals involved in my care to release
healthcare information for purposes of treatment, payment, and/or healthcare operations.
VI.
Disclosure to Friends and/or Family Members
I give permission for my Protected Health Information to be disclosed for purposes of coordinating health care
needs, communicating results, findings and care decisions to the friends and/or family members listed below:
Name
Relationship
Contact Number
**You have the right to revoke whom we talk with about your health care at anytime. Please complete a new consent if you
wish to add or delete a friend and/or family member.
TCCH #1002 Effective 1.17
INITIAL
VII.
Consent for Use and Disclosure of Protected Health Information (PHI)
Yes
No
May we call your job and leave a message?
If yes, at what number?
VIII.
May we call your home and leave a message?
If yes, at what number?
May we leave a message concerning your treatment or services rendered on
your cell phone? If yes, at what number?
Treasure Coast Community Health, Inc. has a patient portal that is available to all patients.
Consent to contact for Appointment Reminders and Other Healthcare Communications.
Patients in our practice may be contacted via our patient portal to remind you of an appointment, to obtain
feedback on your experience with our healthcare team, and to provide general health
reminders/information.
You may set-up your patient portal at https://tcch.portalforpatients.com. The practice will provide you
with a PIN to connect your account to your patient records.
I consent to receive messages for: appointment reminders, feedback, and general health
reminders/information on the patient portal
I understand that if at any time I use my patient portal inappropriately I will lose my rights to the
Treasure Coast Community Health, Inc. patient portal.
IX.
Cancellation Policy
Patients that need to cancel or reschedule an appointment may do so by calling TCCH at 772-257-8224.
Appointment cancellation requires 24-hour advanced notice.
X.
Patient Bills of Rights
The Patient Bill of Rights is posted in the lobby. I acknowledge that I have been offered and/or received a copy of
the Bill of Rights.
XI.
HIV, Hepatitis B & C Testing
In the event that Center staff comes in contact with my or my children’s body fluids, I consent to be tested for HIV,
Hepatitis B and C at no charge.
XII.
Notice of Policy Regarding Advanced Directives (for patients over 18 years of age)
Advanced Directives are legal statements that indicate the type of medical treatment wanted or not wanted in
the event an individual is unable to make decisions as well as who is authorized to make them. Advance
directives are made and witnessed prior to serious injury.
In accordance with federal and state law, this serves as notification that we will set aside your advance
directive in the event you experience a life threatening event while at one of Treasure Coast Community
Health’s centers and you will be transferred to a higher level of care.
By signing below, you agree and understand this as notification.
Please indicate below whether or not you have an advanced directive or if you would like to receive information
on advance directives.
 I have an advanced directive.
 I do not have an advanced directive.
 I would like to receive information on advanced directives.
XIII.
I authorize direct payment to TCCH and all entities of TCCH for the treatment rendered and
understand that I am responsible for final payment of medical services regardless of my insurance
coverage.
XIV.
Dental Welcome Letter: I acknowledge that I have received and read the Dental Welcome Letter
×
Signature of Patient or Parent/Guardian
Date
TCCH #1002 Effective 1.17
Dental Medical History
Patient’s Name:
DOB:
CHECK ALL ITEMS THAT APPLY TO YOUR HISTORY
ADHD/ADD
Syncope (Fainting)
Anxiety Disorder
Alzheimer's/Parkinson's
Arthritis
Artificial Joint Replacements
Asthma
Bleeding-Excessive
Blood Disease
Bone Disease
Brain Stimulation Device (DBS)
Cancer
Central Nervous System Disorder
Chronic Pain Management
Obstructive Lung Disease (COPD)
Lung Problems - Other
Developmentally Challenged
Kidney Dialysis
Organ Transplant-Lung, Kidney, Liver, Pancrease,
Bone Marrow (Cirlce)
Diabetes Type 1 (Insulin)
Diabetes Type 2 (Oral Medication)
Eating Disorder
Emphysema
Thyroid, Parathyroid, Adrenal, Pituitary Problems
Eye Disorder
Injury to: Face, TMJ, or Jaw
Stomach/Intestine Disorder
Gout
Heaptitis A, B, or C: DATE:
High Blood Pressure
Low Blood Pressure
HIV/AIDS: DATE:
Immune System Disorder: DATE:
Kidney, Liver, or Pancreatic Disease
Lupus
Mental Disorder
Multiple Myeloma
Osteoporosis
Cebrebal Palsy
Autism
Post Traumatic Stress Disorder
Radiation to Head, Jaws, or Neck
Severe Nightmares
Sleep Apnea (Snoring)
Seizure Disorder
Sexually Transmitted Disease
Hearing Impaired
Heart Pain-Angina
Vascular Surgery
FEMALES:
Heart Attack (M.I.): Dates:
Heart Stent(S): Dates:
Heart Disease
Heart Infection (Endocarditis)
Pacemaker or Defibrillator
Pregnant Now
Nursing Now
Trying to get Pregnant
Taking Fertility Drugs
Practicing Birth Control
Heart Surgery: Dates:
Artificial Heart Valve (Circle): Tissue or
Mechanical
Substance Abuse: Alcohol, Drugs, Other
Surgery - Other
Stroke
Sinus Problems
Speech Problems
TMJ Problems
Thrombo Embolism
Tobacco Use
Tumors
Ulcers
Page 1 – Turn Over
Dental Medical History
NOW TAKING MEDICATION FOR ANY OF THE FOLLOWING CONDITIONS (CHECK & CIRCLE):
ADHD/ADD
Allergies
Adrenal, Thyroid, Parathyroid, or
Pituitary Gland Problem
Birth Control
Pain-Codeine, Percocet,
Tramadol, Morphine, Demerol,
or Pain Patch
Osteoporosis
Pain - Ibupropehn, Motrin,
Celebrex
Cancer - Radiation Treatment
Cancer - Medication
Cancer Involvement of Bones
Blood Thinners - Coumadin,
Pradaxa, Heparin
Blood Pressure Regulation
Anti Platelet/Clotting - Plavix,
Aspirin
Aspirin 325mg
Aspirin 81mg
Alzheimer's or Parkinson's
Anti-Seizure
Anxiety
Bone Problems
Breathing Problems - Oxygen
Therapy
Breathing Problems - Inhalers
Heart Problems
HAVE YOU EVER HAD ALLERGIES TO:
Depression
Sedatives or Sleep Aids
Fertility
Cholesterol Management
Anti Inflammatory - Prednisone, Cortisone
Chronic Pain Management
Diabetes Type 1
Diabetes Type 2
Ulcers, Stomach or Intenstinal Problems
Hepatitis
HIV/AIDS
Hormone - Estrogen
Non Prescription Street Drugs
Immune Suppresive Drugs
Kidney, Urinary, Prostate Problems
Multiple Sclerosis
Multiple Myeloma
Plasma Products or Blood Factors
Heart Rhythm Problems
EVER TAKE ANY OF THE FOLLOWING?(CIRCLE)
Actonel, Aredia, Boniva, Fosomax, Zometa
(Notrogen Conaining Bisphosponates)
Atelvia, Didronel, Reclast, Skelid (Non-Nitrogen
Containing Bisphosphonates)
All of the answers above are true and correct. If I have any changes in my Health or my
Medications, I will notify the Doctor at my next appointment without fail.
Patient/Guardian Signature:
DATE:
Medical History:
Patient Name:
Date of Birth:
CHECK ALL ITEMS THAT APPLY TO YOUR HISTORY
ADHD/ADD
Syncope (Fainting)
Anxiety Disorder
Alzheimer's/Parkinson's
Arthritis
Artificial Joint Replacements
Asthma
Bleeding-Excessive
Blood Disease
Bone Disease
Brain Stimulation Device (DBS)
Cancer
Central Nervous System Disorder
Chronic Pain Management
Obstructive Lung Disease (COPD)
Lung Problems - Other
Developmentally Challenged
Kidney Dialysis
Organ Transplant-Lung, Kidney, Liver,
Pancrease, Bone Marrow (Cirlce)
Diabetes Type 1 (Insulin)
Diabetes Type 2 (Oral Medication)
Eating Disorder
Emphysema
Thyroid, Parathyroid, Adrenal, Pituitary
Problems
Eye Disorder
Injury to: Face, TMJ, or Jaw
Stomach/Intestine Disorder
Gout
Hearing Impaired
Heart Pain-Angina
Heart Attack (M.I.): Dates:
Heart Stent(S): Dates:
Heart Disease
Heart Infection (Endocarditis)
Pacemaker or Defibrillator
Heart Surgery: Dates:
Artificial Heart Valve (Circle): Tissue or Mechanical
Heaptitis A, B, or C: DATE:
High Blood Pressure
Low Blood Pressure
HIV/AIDS: DATE:
Immune System Disorder: DATE:
Kidney, Liver, or Pancreatic Disease
Lupus
Mental Disorder
Multiple Myeloma
Osteoporosis
Cebrebal Palsy
Autism
Post Traumatic Stress Disorder
Radiation to Head, Jaws, or Neck
Severe Nightmares
Sleep Apnea (Snoring)
Seizure Disorder
Sexually Transmitted Disease
Substance Abuse: Alcohol, Drugs, Other
Surgery - Other
Stroke
Sinus Problems
Speech Problems
TMJ Problems
Thrombo Embolism
Tobacco Use
Tumors
Ulcers
Vascular Surgery
FEMALES:
Pregnant Now
Nursing Now
Trying to get Pregnant
Taking Fertility Drugs
Practicing Birth Control
PAGE 1 - TURN OVER
NOW TAKING MEDICATION FOR ANY OF THE FOLLOWING CONDITIONS (CHECK & CIRCLE):
ADHD/ADD
Allergies
Adrenal, Thyroid, Parathyroid, or Pituitary Gland
Problem
Birth Control
Pain-Codeine, Percocet, Tramadol, Morphine,
Demerol, or Pain Patch
Osteoporosis
Pain - Ibupropehn, Motrin, Celebrex
Cancer - Radiation Treatment
Cancer - Medication
Cancer Involvement of Bones
Blood Thinners - Coumadin, Pradaxa, Heparin
Blood Pressure Regulation
Anti Platelet/Clotting - Plavix, Aspirin
Aspirin 325mg
Aspirin 81mg
Alzheimer's or Parkinson's
Anti-Seizure
Anxiety
Bone Problems
Breathing Problems - Oxygen Therapy
Breathing Problems - Inhalers
Heart Problems
Depression
Sedatives or Sleep Aids
Fertility
Cholesterol Management
Anti Inflammatory - Prednisone, Cortisone
Chronic Pain Management
Diabetes Type 1
Diabetes Type 2
Ulcers, Stomach or Intenstinal Problems
Hepatitis
HIV/AIDS
Hormone - Estrogen
Non Prescription Street Drugs
Immune Suppresive Drugs
Kidney, Urinary, Prostate Problems
Multiple Sclerosis
Multiple Myeloma
Plasma Products or Blood Factors
Heart Rhythm Problems
EVER TAKE ANY OF THE FOLLOWING?(CIRCLE & CHECK)
Actonel, Aredia, Boniva, Fosomax, Zometa
(Notrogen Conaining Bisphosponates)
Atelvia, Didronel, Reclast, Skelid (NonNitrogen Containing Bisphosphonates)
HAVE YOU EVER HAD ALLERGIES TO:
Any Foods:
Barbituates, Sedatives, or Sleeping Pills
Local Anesthetics (such as Novacain, Ldiocaine,
Penicillin, Amoxicilllin, Ampicillin,
Mepivicaine, etc.) Other:
Augmentin (Penicillin Family)
Erythromycin
Narcotics:
Hydocodone
Tetracycline:
Oxycodone
Demerol
Other
Zithromax (Azithromycin)
Acetaminophen (Tylenol)
Cipro
Aspirin
Clindamycin
Aleve
Metals:
Codeine
Latex (Rubber)
Tramadol
Keflex (Cephalosporin Family)
Sulfa Drugs
Ibuprofen - (Motrin, Advil or Generic Ibuprofen)
Other Drugs
Name of any other antibiotic allergy:
Hay Fever/Seasonal
Barbituates, Sedatives or Sleeping Pills
Other
Iodine
All of the answers above are true and correct. If I have any changes in my Health or my Medications, I will notify the Doctor
at my next appointment without fail.
Patient/Guardian Signature:
DATE: