Authorization and Consent for Photography

Authorization and Consent for Photography

In an effort to save time for our patients and clinic staff we have provided the necessary
medical and dental forms needed prior to seeing a Clinician. If you are a new patient or an
existing patient with information that has changed, please click on the appropriate link below
to download and print the necessary forms.
Please bring the filled out forms with you and make sure to arrive 15 minutes before your
appointment. If you have any questions please call the Clinic where your appointment is
scheduled. Thank You!
Authorization and Consent for Photography
AUTHORIZATION AND CONSENT FOR PHOTOGRAPHY
AUTORIZACIÓN Y CONSENTIMIENTO PARA USO DE FOTOGRAFÍAS
Patient Name: ID: DOB: Gender:
The undersigned herby authorizes Santa Barbara Neighborhood Clinics to photograph . The undersigned agrees that the above named
organization may not use and permit other persons to use the negative print prepared from such photograph for any purpose other
than the dental record.
La persona que aquí firma da su autorización por este medio a Las Clínicas de Santa Barbara Neighborhood, para tomar fotos . La
persona que aquí firma está de acuerdo en que la organización arriba mencionada, no pueda usar y permitir que otras personas utilicen
las impresiones negativas pareparadas por este fotógrafo para otro fin más que el expediente dental.
I, decline to have my photograph taken.
Yo, me niego a ser fotografiado.
Signature: Date:
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Consent for Treatment
I hereby grant authority to the dentist(s) in charge of the care of __________________________________ to administer
such anesthetic, analgesics or x-rays necessary and to perform such operations as may be deemed necessary or advisable
in the diagnosis and treatment of this patient. I have been informed of possible complications of the procedures,
anesthetics and/or drugs.
I have been given the opportunity to ask questions regarding the nature and purpose of dental treatment and have
received answers to my satisfaction. In case of any complications where the dentist(s) determines a referral to another
dentist or specialist, I understand it will be my full financial responsibility. Fee(s) for these services, have been/will be
explained to me to my satisfaction. By signing this form, I am freely giving my consent to allow and authorize Eastside
Family Dental Clinic to render any treatment necessary.
I hereby acknowledge that I have been offered a copy of the Notice of Privacy Policies of SBNC and consent to each
of those policies as set forth in the current notice as posted in the reception area of the clinic.
X__________________________________________
X________________________________________
Date Here
Signature of Patient or Legal
guardian
I have received/read a copy of the Dental Materials Fact Sheet required by law.
__________________
Initials
**************************************************************************************************
Consentimiento Para Tratamiento
Doy mi autorizacion al Dentista que esta al cuidado de ________________________________para administrar
aneslesia, analgesicos o tomar las radiografias necesarias para el diagnostic y el tratamiento de este paciente. Se me ha
informado de posibles complicaciones con el tratamiento, aneslesia y/o medicamento.
Se me ha dado la oportunidad de la naturaleza y proposito de el tratamiento y e recibido respuestas satifactorias.
En caso de complicaciones, donde el Dentista determine una referencia a un especialista, yo entiendo que va a ser mi
responsbilidad financier.
Los pagos para estos servicios han sido explicados a mis satifacion.
Al fimar esta forma, do mi consentimiento y autorizo a Eastside Family Dental Clinic render el tratamiento
recomendado.
Confirmo por la presente haber recibido una copia del Aviso sobre la política sobre uso de la información confidencial de
SBNC y doy mi conformidad con ellas tal como aparecen en el aviso que hay actualmente en la recepción de la clínica.
X__________________________________________
X________________________________________
Firma del paciente o
persona en cargo
Yo recibi/lei la Hoja informative sobre Materiales Dentales requerido por la ley.
Fecha
____________
Iniciales
Today’s Date: _____________________________
Patient Name: _________________________________________ Date of Birth: _____________________________
MM/DD/YYYY
Patient Information
Sex: MaleFemale Patient SS#:__________________________ Home Phone:________________________
Alternate Phone: _______________________________ E-mail: __________________________________________
Patient Address: __________________________________________________________________________________
Street Address, City, State, Zip Code
__________________________________________________________________________________________________
Street Address, City, State Zip Code
May we contact you at home? Yes No May we contact you by alternate phone? Yes No
May we contact you by U.S. mail? Yes No May we contact you by e-mail? Yes No
Head of Household (mother, father,
guardian)
Demographics
Marital Status: Single w/partner Single w/o partner Married Divorced Separated Widow/er
Race: (Select one or
more)
American Indian/
Alaskan Native
Asian
Black/ African
American
More than one
race
Native Hawaiian
Other Pacific
Islander
White
Other (Must Specify):
_________________
Ethnicity (select
one):
Hispanic/
Latino
Not Hispanic/
Latino
Refused
Do you smoke?
Yes No
Are you a veteran?
Yes No
Do you have a
language
barrier?
Yes No
Primary
Language:
English
Spanish
Other (Must
Specify):
_______________
Present Living
situation:
Own a Home
Rent a Home,
apartment, or room
Shelter
Street
Doubling up
Transitional
Other:
___________________
Are you an
Agricultural, Cattle,
or Poultry Farm
Worker?
Migrant
Seasonal
Not a farm worker
Do you have permanent housing?
Yes No
How long have you lived there? ______
Do you consider your housing stable?
Yes No
How many times have you moved in
the last year? _______________________
Is there a threat of losing your housing?
Yes No
Have you been homeless in the last 12
months? Yes No
How long have you lived in Santa
Barbara County? ____________________
Is this patient the Responsible Party (over 18 years of age, legally responsible for self)? Yes No
If yes, skip to Household Income at the bottom right of this section.
Responsible party name:_________________________________________________ D.O.B.__________________
Other parent/guardian name:____________________________________________________________________
Relationship to patient:_____________________________________ SS#:__________________________________
Address (if the same as patient, write “same”): ____________________________________________________
Street Address, City, State, Zip Code
_________________________________________________________________________________________________
Street Address, City, State, Zip Code
_________________________________________________________________________________________________
Street Address, City, State, Zip Code
Home Phone:___________________________________ Alternate Phone: ________________________________
Cell Phone:___________________________________ Household Income $____________ Family Size: _______
SBNC20120628Revised20121217Revised20130320
Emergency Contact
Emergency Contact: It is important that we have an Emergency Contact name and phone number
in the event we cannot reach you. We will not disclose personal, confidential information to this person
without your consent. (This number must be different from your phone number).
7123
Name:__________________________________________________ Phone number: ___________________________
Relationship to Patient:_____________________________________________________________________________
May we discuss your medical information with this person? Yes No Is there another person with
whom we can discuss your medical condition in the case that you are incapacitated, or if we cannot
reach you? Yes No If yes provide contact information:
Contact name: ___________________________________________________________________________________
Insurance Information
Phone:____________________________________________________________________________________________
Primary Insurance Name: ________________________________________________ ID #:____________________
Name of Insured, if not patient: ___________________________________________________________________
Secondary Insurance Name:_____________________________________________ ID #:____________________
Name of Insured, if not patient:____________________________________________________________________
Third Insurance Name:____________________________________________________ ID #:___________________
Name of Insured, if not patient:____________________________________________________________________
Miscellaneous
How did you learn about this clinic?
Advertising
Facebook
Health Fair
Printed Ad
CARE/ADMHS
Flyer/Brochure
Insurance
Promoter
SBNC
Employee
Sansum
Church
Friend/Relative
Internet
Radio
Other
Daycare
CenCal Health
Non-profits
Referral
County Clinic
Television
Phone Book
Teen Health Advocate
ER/ED
School
Presentation
Cottage Health System
Acknowledgements: I have executed a copy of the SBNC Consent for Treatment and Evaluation &
Acknowledgement of Receipt of Notice of Privacy Practices and I consent to the matters contained therein. By
signing below I acknowledge that I have received an information sheet on Advanced Healthcare Directives.
Signature of Patient or Responsible Party: ____________________________________________________________________
SBNC20120628Revised20121217Revised20130320
PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY (HISTORIAL MÉDICO DEL PACIENTE )
PATIENT NAME. NOMBRE DEL PACIENTE :
HOME ADDRESS. DOMICILIO: BUSINESS ADDRESS. DOMICILIO DEL NEGOCIO :
E -MAIL:
DATE OF BIRTH. FECHA DE NACIMIENTO :
HOME PHONE. TELÉFONO DE CASA : CELL PHONE. CELULAR :
TODAY'S DATE. FECHA DE HOY :
BUSINESS PHONE. TELÉFONO DE NEGOCIO :
SSN. Nº DE SEGURO:
ID:
PHYSICIAN. MÉDICO :
OFFICE PHONE. TELÉFONO DE OFICINA:
DATE OF LAST MEDICAL EXAM. FECHA DEL ÚLTIMO EXAMEN MÉDICO :
BLOOD PRESSURE. PRESIÓN ARTERIAL :
YES
SÍ
NO
1. ARE YOU UNDER MEDICAL TREATMENT NOW? IF YES, DESCRIBE.
¿ACTUALMENTE ESTÁ USTED BAJO TRATAMIENTO MÉDICO? SI SU RESPUESTA ES SÍ, DESCRIBA .
2. HAVE YOU EVER BEEN HOSPITALIZED FOR ANY SURGICAL OPERATION OR SERIOUS ILLNESS? IF YES, DESCRIBE.
¿HA ESTADO HOSPITALIZADO POR ALGUNA INTERVENCION QUIRÚRGICA O ENFERMEDAD GRAVE? SI SU RESPUESTA ES SÍ, DESCRIBA .
3. ARE YOU TAKING ANY MEDICATION(S) INCLUDING NON-PRESCRIPTION MEDICINE? IF YES, DESCRIBE.
¿ESTÁ TOMANDO ALGÚN MEDICAMENTO(S) INCLUYENDO MEDICAMENTOS SIN RECETA? SI SU RESPUESTA ES SÍ, DESCRIBA .
4. ARE YOU TAKING ANY OF THE FOLLOWING? ¿ESTÁ TOMANDO ALGUNO DE LOS SIGUIENTES ?
A. ANTIBIOTICS OR SULFA DRUGS. ANTIBIÓTICOS O SULFAMIDAS.
B. ANTIOCOAGULANTS (BLOOD THINNERS SUCH AS COUMADIN, PLAVIX ETC.). ANTIOCIOANGULANTES (ADELGANZANTES DE SANGRE TALES COMO: COUMADIN, PLAVIX
ETC.).
C. MEDICINE FOR BLOOD PRESSURE. MEDICAMENTOS PARA LA PRESION ARTERIAL.
D. CORTISONE (STEROIDS). CORTISONA (ESTEROIDES).
E. TRANQUILIZERS. TRANQUILIZANTES.
F. INSULIN, TOLBUTAMIDE (ORINASE) OR A SIMILAR DRUG. INSULINA, TOLBUTAMIDE (ORINASE) O MEDICAMENTO SIMILAR.
G. DIGITALIS OR DRUGS FOR HEART TROUBLE. DIGITALIS U OTRO MEDICAMENTO PARA ENFERMEDADES CARDÍACAS.
H. NITROGLYCERIN. NITROGLICERINA.
I. ORAL CONTRACEPTIVES. ANTICONCEPTIVOS ORALES.
K. DILANTIN
L. DEPAKOTE
M. CHEMOTHERAPY DRUGS. MEDICAMENTOS PARA QUIMIOTERAPIA.
N. OSTEOPOROSIS DRUGS (FOSAMAX, AREDIA, ZOMETA ETC.). MEDICAMENTOS PARA LA OSTEPOROSIS (FOSAMAX, AREDIA, ZOMETA, ETC.).
5. DO YOU HAVE A PERSISTENT COUGH OR THROAT CLEARING NOT ASSOCIATED WITH KNOWN ILLNESS (LASTING MORE THAN 3 WEEKS)?
¿TIENE USTED TOS PERSISTENTES O CARRASPERA EN LA GARGANTA NO ASOCIADA CON ALGUNA ENFERMEDAD CONOCIDA (POR MAS DE 3 SEMANAS)?
6. DO YOU USE TOBACCO? ¿USA USTED TABACO?
IF YES, HOW MUCH? SI CONTESTO SÍ, ¿CUÁNTO?
WOULD YOU LIKE HELP TO QUIT? ¿LE GUSTARÍA RECIBIR AYUDA PARA DEJARLO?
Yes
No
7. ARE YOU ADDICTED TO OR RECOVERING FROM ANY DRUG OR ALCOHOL ADDICTION?
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PATIENT MEDICAL HISTORY
¿ES USTED ADICTO O ESTÁ RECUPERANDOSE DE ALGUNA ADICCIÓN A DROGAS O ALCOHOL?
8. DO YOU USE OR HAVE YOU USED RECREATIONAL DRUG OR MEDICINAL MARIJUANA? ¿USA O HA USADO DROGA RECREATIVA O MARIJUANA MEDICINAL?
9. ARE YOU ALLERGIC TO OR HAVE YOU HAD ANY REACTIONS TO THE FOLLOWING?
¿ES USTED ALÉRGICO O HA TENIDO ALGUNA REACCIÓN A LOS SIGUIENTE?
LATEX.
LOCAL ANESTHETICS (EX: NOVOCAINE). ANESTESICOS LOCALES (EX: LA NOVOCAINA).
PENICILLIN OR OTHER ANTIBIOTICS. PENICILINA U OTROS ANTIOBIÓTICOS.
SULFA DRUGS. SULFAMIDAS.
BARBITURATES. BARBITÚRICOS.
ASPIRIN. ASPIRINA.
CODEINE. CODEÍNA.
SEDATIVES. SEDANTES.
10. DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING? ¿TIENE O HA TIENDO CUALQUIERA DE LOS SIGUIENTES ?
YES
SÍ
NO
A. HIGH BLOOD PRESSURE. ALTA PRESIÓN
B. HEART ATTACK; IF YES WHEN. INFARTO CARDÍACO; SI RESPONDIÓ SÍ, CUÁNDO.
C. STROKE; IF YES WHEN. EMBOLIA; SI RESPONDIO SÍ, CUÁNDO.
D. PROSTHETIC CARDIAC VALVE. PROTESIS VALVULAR CARDÍACA
E. INFECTIVE ENDOCARDITIS. ENDOCARDITIS INFECCIOSA.
F. CONGENITAL HEART DISEASE. ENFERMEDAD CONGENITA CARDÍACA.
G. ANGINA PECTORIS. ANGINA DE PECHO.
H. CHEST PAINS. DOLORES DE PECHO.
I. CARDIAC PACEMAKER. MARCAPASOS.
J. DIABETES
K. SWOLLEN ANKLES. TOBILLOS HINCHADOS.
L. EPILEPSY/CONVULSIONS. EPILEPSIA/CONVULSIONES.
M. EASILY WINDED. QUEDARSE SIN ALIENTO FÁCILMENTE.
N. FREQUENTLY TIRED. FRECUENTEMENTE CANSADO.
O. CANCER; IF YES, DESCRIBE. CANCER; SI RESPONDIÓ SÍ, DESCRIBA.
P. AIDS OR HIV INFECTION. SIDA Ó INFECCIÓN DE VIH.
Q. ANEMIA OR OTHER BLOOD DISEASE. ANEMIA U OTRA ENFERMEDAD DE LA SANGRE.
R. BLEEDING TENDENCY/ABNORMAL BLEEDING. TENDENCIA A SANGRAR/ SANGRADO ANORMAL.
S. LEUKEMIA. LEUCEMIA.
T. RECENT WEIGHT LOSS. PÉRDIDA DE PESO RECIENTE.
U. ASTHMA. ASMA. IF YES, DO YOU HAVE AN INHALER? SI RESPONDIÓ SÍ, TIENE UN INHALADOR?
YES. SÍ NO
V. RADIATION THERAPY. RADIOTERAPIA.
W. STOMACH ULCER. ÚLCERA DE ESTÓMAGO.
X. THYROID PROBLEM. PROBLEMA DE TIROIDES.
Y. KIDNEY DISEASE. ENFERMEDAD RENAL.
Z. ARTHRITIS. ARTRITIS.
a. FAINTING/SEIZURES. DESMAYANDO/ ATAQUES.
b. LOW BLOOD PRESSURE. PRESIÓN ARTERIAL BAJA.
c. SEXUALLY TRANSMITTED DISEASE. ENFERMEDADES TRANSMITIDAS SEXUALMENTE.
d. HEPATITIS/JAUNDICE/LIVER DISEASE. HEPATITIS/ICTERCIA/ AFECCIÓN HEPÁTICA.
TYPE. TIPO:
A B C UNKNOWN. NO SE SABE.
WOMEN ONLY. SÓLO LAS MUJERES.
YES
NO
SÍ
ARE YOU PREGNANT OR THINK YOU MAY BE PREGNANT? ¿ESTÁ EMBARAZADA O PIENSA QUE PUEDA ESTAR EMBARAZADA?
ARE YOU NURSING? ¿ESTÁ DANDO PECHO?
ARE YOU TAKING BIRTH CONTROL PILLS? ¿ESTÁ TOMANDO PASTILLAS ANTICONCEPTIVAS?
COMMENTS:
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PATIENT MEDICAL HISTORY
SIGNATURE: I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. TO THE BEST OF MY KNOWLEDGE, THE ABOVE QUESTIONS HAVE BEEN ACCURATELY
ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH
FIRMA: CERTIFICO QUE HE LEÍDO Y ENTENDIDO LA INFORMACIÓN ARRIBA SEÑALADA. A MI MEJOR CONOCIMIENTO, LAS PREGUNTAS HAN SIDO CONTESTADAS CON PRECISIÓN.
ENTIENDO QUE EL PROVEER INFORMACIÓN INCORRECTA PUEDE SER PELIGROSO PARA MI SALUD
PATIENT/PARENT/GUARDIAN. PACIENTE/PADRE/GUARDIÁN. : DATE. FECHA. DENTIST. DENTISTA. : DATE. FECHA. : file:///D|/...ocal/Microsoft/Windows/Temporary Internet Files/Content.Outlook/694QQG4M/ESFDC PATIENT MEDICAL HISTORY.html[9/25/2012 10:08:45 AM]
SBNC: SLIDING FEE SCALE ELIGIBILITY DETERMINATION APPLICATION
Income: $__________________ Circle One: Weekly Monthly Yearly
Financial Verification Source and Attach Copy (Circle One):
Tax Return
Check Stubs
Unemployment
Supplemental Security Incom (SSI)
Social Security Disability Insurance (SSDI)
Other:______________________
Family Size: ____________
(Self, spouse and children under 18 years of age)
I certify that under penalty of perjury that I am NOT eligible or currently covered by
CenCal/Medi-Cal, Medicare, or any other private insurance.
I understand payment is due and collected at the time of service.
Initial:
I understand Medications are an additional charge.
Initial:
I understand Labs are an additional charge.
Initial:
I understand procedures are an additional charge.
Initial:
I understand specialty appointments are an additional charge.
Initial:
Patient Name_______________________________________________ Date of Birth:___________
Patient/Parent/Guardian Signature__________________________________Date:_____________
Patient Name:_________________________________ DOB:________________MRN:___________
For Internal Use Only:
Sliding Fee:
Copayment:
Termination Date:
Staff Initials/ Title: