APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC

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1 APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC Patient Information (To be completed by the patient Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: Date: / / First Name: (Preferred Name) Middle Name: Billing Address: City: State: Zip Code: Home Phone: ( ) Work Phone: ( ) Preferred Phone: ( ) Address: Driver s License: California ID: [ ] Other Passport: Employer: Sex: [ ] Male [ ] Female [ ] Other Birth date: Primary Language(s) Spoken: Are you associated with U.S.C.? Yes [ ] No [ ] If so, how? Student Requested: To guide us in assigning a student whose schedule matches your availability, You must indicate at least 3 with a þ the sessions for which you are regularly available: Note: AM session 8:00am and PM session is 1:00pm r Monday AM r Monday PM r Tuesday PM r Wednesday AM r Wednesday PM r Thursday AM r Thursday PM r Friday AM r Friday PM r Tuesday Night Clinic Emergency Contact: Relationship: Emergency Contact Phone: ( ) Major dental problem/reason for coming to USC School of Dentistry: Last Dentist: Phone: ( ) Address: City: State: Zip: Current Medical Doctor: Phone: ( ) Address: City: State: Zip: Insurance/Financial Information (To be completed by the patient Please PRINT in ink) Previously a patient here? [ ] Yes [ ] No Year: Insurance: [ ] Delta [ ] Delta/USC [ ] Denti-Cal [ ] Other Carrier Name: Subscriber: Subs. #: Subs. Birthdate: Relationship: Plan #: Group #: Person Responsible for Payment: Phone: Please be aware that your dental insurance may not pay for the total amount of your treatment and you may be responsible for any co-pays or amount that your insurance company does not cover. Revised 6/12, 6/13, 3/15, 6/15,10/2015, Ethnicity: (please select) [ ] African American [ ] Asian [ ] Caucasian [ ] Hispanic [ ] American Indian/Alaskan native [ ] Pacific Islander [ ] Unknown [ ] Other

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12 WELCOME TO THE HERMAN OSTROW SCHOOL OF DENTISTRY OF USC Today you will be screened by one of the school faculty. The faculty will decide if your oral condition is: A. An emergency case. B. Not a case that we can offer treatment at this school. C. A teaching case for our post-graduate students. D. A teaching case for our pre-doctoral dental students. A) If your oral condition is an emergency case, you will be referred to our Urgent Care Clinic in this building. B) If your oral condition is a case that we cannot treat at this school, we will provide you with information about other low fee clinics. C) If your oral condition is a teaching case for our post-graduate students; you will be redirected to a specific clinic in the school that can better address your needs. These post-graduate clinics will have their own appointment schedules and their own screening processes. We cannot guarantee that the faculty of a postgraduate clinic will accept your case. D) If your oral condition is a teaching case for our pre-doctoral dental students: You MUST select at least 3 clinic sessions on the application to be accepted as a patient. We will first make sure that you understand and agree with the Dental Students Clinic Policies (please read the next section for details). You will then be sent to the cashier to pay between $20-$100. The fee includes your admitting fee, and your X-rays (panoramic and/or full mouth X-rays when necessary). After paying your fee at the cashier, have a seat and you will be called by radiology department. Show proof of payment to radiology staff. X-rays: A panoramic X-ray and/or a full mouth X-rays will be done if necessary. A fee in the amount of $55 will be due at your next appointment with your assigned dental student for data collection and treatment planning. A pre-doctoral dental student will call you within then FOUR WEEKS to set up your next appointment. If you do not receive a call from the assigned pre-doctoral dental student within this period. Please call the Administrative Assistant from your assigned group and say you are waiting for your appointment. For group A: Call Lizbeth Herrera (213) For group B: Call Vivian Martinez (213) For group C: Call Yvonne Mercado (213) For group D: Call JoAnne Williams (213) For group E: Call Oralis Castillo Lazaro (213) For group F: Call Brenda Castillos (213) For group G: Call Tara Lam (213) For group H: Call Raul Gamboa (213) For group I: Call Lisette Amandor (213)

13 HERMAN OSTROW SCHOOL OF DENTISTRY OF USC DENTAL STUDENTS CLINIC POLICIES 1. This teaching institution, and all the dental work will be done by pre-doctoral dental students in a stepwise manner. 2. This is a fee-for-service clinic; IT IS NOT A FREE CLINIC. 3. The dental work will be done in a specific order of importance. For example: we cannot do a restoration or a crown before addressing other problems such as abscessed teeth or periodontal (gum) disease. 4. The pre-doctoral dental student will be working under supervision of a faculty member. 5. The appointments take about 3-4 hours (all morning or all afternoon). 6. We have night clinics on Tuesday from 6:00 to 9:00 P.M. 7. The appointments are arranged between the patient and the student doctor assigned to the case. 8. During the first two or three visits the students will do data collection that includes, but is not limited to, the following procedures: review of your medical history, review of your medications, examination of your face, neck, and oral soft tissues for any abnormalities, study of X-rays, examination of your teeth, examination of your gums, and impressions. 9. At the end of the data collection you will be given a treatment plan appointment. You will then know what needs to be done and your different options of treatment with specific fees associated to that. The student should also be able to give you an estimate of the time necessary for treatment. Please sign below if you understand and agree with these policies. If you have any questions you can ask the faculty during your screening and sign it after. Patient: Witness (Faculty): Date: Date: 9/14, rev. 3/15, 10/2017 2

14 PATIENT COPY HERMAN OSTROW SCHOOL OF DENTISTRY OF USC DENTAL STUDENTS CLINIC POLICIES 1. This teaching institution, and all the dental work will be done by pre-doctoral dental students in a stepwise manner. 2. This is a fee-for-service clinic; IT IS NOT A FREE CLINIC. 3. The dental work will be done in a specific order of importance. For example: we cannot do a restoration or a crown before addressing other problems such as abscessed teeth or periodontal (gum) disease. 4. The pre-doctoral dental student will be working under supervision of a faculty member. 5. The appointments take about 3-4 hours (all morning or all afternoon). 6. We have night clinics on Tuesday and Wednesday from 6:00 to 9:00 P.M. 7. The appointments are arranged between the patient and the student doctor assigned to the case. 8. During the first two or three visits the students will do data collection that includes, but is not limited to, the following procedures: review of your medical history, review of your medications, examination of your face, neck, and oral soft tissues for any abnormalities, study of X-rays, examination of your teeth, examination of your gums, and impressions. 9. At the end of the data collection you will be given a treatment plan appointment. You will then know what needs to be done and your different options of treatment with specific fees associated to that. The student should also be able to give you an estimate of the time necessary for treatment. Please sign below if you understand and agree with these policies. If you have any questions you can ask the faculty during your screening and sign it after. Patient: Witness (Faculty): Date: Date: CHART COPY 9/14, rev. 3/15, 10/2017 3

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APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC

APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC APPLICATION FOR TREATMENT Chart # Herman Ostrow School of Dentistry of USC Patient Information (To be completed by the patient Please PRINT in ink) Mr. ( ) Mrs. ( ) Ms. ( ) Last Name: Date: / / First Name:

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