UMMC School of Dentistry Dental Mission Week 2019 February 5th 8th
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- Lesley Blake
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1 UMMC School of Dentistry Dental Mission Week 2019 February 5th 8th Dear Applicant, Thank you for your interest in our Dental Mission Week event. To apply for the free dental services that will be offered, please fully complete the attached forms and return them to this location before January 10, If you are selected, you will be contacted and given a day and time to come to the UMMC School of Dentistry to be screened for treatment. For your convenience, on your application please provide a working phone number in which you may be contacted. Note: If you DO NOT have an appointment time, you will not be seen. Please do not come to the School of Dentistry if you are not contacted with an appointment time. We will not be able to treat unscheduled walk-in patients. For more information: Call (601)
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3 2500 North State Street Jackson, MS Date: Patient Information: Please Print & Sign LAST Name (Apellidos): FIRST Name (Nombre): Date of Birth (Nacimiento): Age (Edad): Address (Direccion): City (Ciudad): County (Condado): State (Estado): Zip (Codigo Posta1): Patient Chief Complaint: Are You in Pain? Yes No Gender (Genero): Patient Phone number: Health History Drug Allergies List Medications You Time of (Check all that apply) (Check all that apply) Are Currently Taking Last Dose Latex Allergy Cardiovascular Reproductive Penicillin Heart Disease _Currently Pregnant Sulfa High/Low Blood Pressure Other Mitral Valve Prolapse Digestive Heart Murmur Ulcers/GERD Are you taking Warfarin? (i.e. Coumadin)? Heart Valve Replacement Hepatitis Yes No Heart Stent If yes, what/when was the most recent INR? / Nervous Endocrine Seizures Are you or have you taken bone strengthening drugs? Diabetes Yes No Presently under a Physician s care: Yes No Last Medical Visit: When? Immune Hematology/Lymphatic Why? HIV+/AIDS Anemia Lupus Excessive Bleeding Scarlet Fever Rheumatic Fever Urinary History of Kidney Disease Muscular/Skeletal Rheumatoid Arthritis Osteoarthritis Joint Replacement Eyes Vision Loss Wear glasses/contacts Respiratory Asthma COPD Chronic Bronchitis Tuberculosis Ear, Nose, Throat Hearing Loss Other Organ Transplant Radiation Treatment Tobacco Use
4 Important Notice UMMC Dental Mission providers may not be able to provide you with all the services you need, but if you would like to consult with our team and receive the type of treatment being offered today, PLEASE READ THE PATIENT WAIVER BELOW VERY CAREFULLY. Dental Patients Note: I understand that because of the number of people needing to be seen, I might not receive multiple extractions or multiple fillings. I understand that I might have certain medical conditions which would keep me from having the type of treatment I am requesting. I also understand that the many of the dental care providers are volunteers, some from out of town, and are not available for follow-up care in the event of complications. Follow-up care is available through the School of Dentistry. In consideration of the free dental care services received on the date below, I for myself and anyone entitled to claim through me, do hereby waive and release the University of Mississippi School of Dentistry, and any other organization or company or persons acting on their behalf or sponsoring or volunteering at this clinic, from all claims of liability arising out of my acceptance of such free care including but not limited to medical, surgical, dental, and/or vision care or other health care or medical advice. I grant to the School of Dentistry at the University of Mississippi and its agents the right to use my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing UMMC Dental Mission Week services and its activities in all forms of media in perpetuity. I have read, or had read to me, and understand and agree to all of the above. Patient signature (parent or guardian if patient is under 18 years or age) Date If under 18, please print guardian s name Is guardian also receiving treatment today? Yes / No If yes, name of Guardian:
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Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
Welcome to Dr Jamie Italiane-DeCubellis s office
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Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
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PATIENT INFORMATION FORM (PLEASE PRINT)
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STEPHEN C. SNITZER, D.D.S.,
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MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
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Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
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ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
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A B O U T Y O U D E N T A L I N F O R M A T I O N
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Patient Medical History
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Patient Registration
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