Authorization and Consent for Photography
Transcripción
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: file:///D|/...ar/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/694QQG4M/SBNC Consent Photography.html[9/25/2012 10:13:13 AM] 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: MaleFemale 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? file:///D|/...ocal/Microsoft/Windows/Temporary Internet Files/Content.Outlook/694QQG4M/ESFDC PATIENT MEDICAL HISTORY.html[9/25/2012 10:08:45 AM] 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: file:///D|/...ocal/Microsoft/Windows/Temporary Internet Files/Content.Outlook/694QQG4M/ESFDC PATIENT MEDICAL HISTORY.html[9/25/2012 10:08:45 AM] 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: