Tufts community dental program

PROGRAM BENEFITS
By signing this form, I am giving consent
to receive dental treatment.
All patients will receive an oral health
1) I understand that dental treatment may include any or all of the following: Dental Some patients may need to be scheduled for
Instruction, Fillings, Other Restorative further dental treatment and will be referred Dentistry, Prosthetics, Prosthodontics, and to either the Martha’s Vineyard Hospital application of local anesthetic xylocaine or Referrals are dependent on the extent of the
3) I understand it is my responsibility to inform the dental provider of any changes in Consent indicates your awareness of
4) I understand that my health information sufficient information to allow you to make your dental treatment. Most patients do not 5) If I have dental insurance, I authorize my insurance carrier to be billed for any services treatment. In rare instances, a patient may These services may include:
experience some discomfort or pain. If the 6) I understand that I may continue to obtain ♦ Routine Dental Screenings & Exams patient indicates any resistance to the dental 7) I understand that treatment provided may affect future rights and benefits of private CONTACT INFORMATION:
I have read and understand this consent
♦ Restorative Dentistry (fillings) form and I authorize the dental program to
CMOHS: Rachel Unwin (508) 947-0111
provide a written summary to participating
providers as needed. I consent to
participate.
Polished: Ellen Gould RDH (508) 237-5378
Signature: __________________________
♦ Recall Visits (Continuous Care) Vineyard Smiles: Sarah Kuh
Printed Name: ______________________
PLEASE SIGN OTHER SIDE!
Date:______________________________
MEDICAL INFORMATION
PATIENT INFORMATION
DENTAL INSURANCE
Please be sure to complete all sections.
Please be sure to complete all sections.
Please have a copy of your MassHealth or Private Dental Insurance Cards (not.Medicare) so we can bill your insurance company for the dental services. ___/___/___/ - ___/___/___/ - ___/___/___/___ ___ I have no dental insurance and will be
personally responsible to pay my bills. I understand a sliding fee scale may be made Do you have any allergies?
available to me to defray some of the costs. If yes, please check all that apply: Antibiotics,
Colophonium, Foods, Latex, Penicillin, ____/____/ - ____/____/ - ____/____/____/____ Resins, Medications (list)_______________
Date of Birth (month / day / year) Medicaid or Private Insurance
Dental Insurance
Do you need antibiotics before dental
____/ ____/ ____/- ____/____/-____/____/____/____
treatment? yes _____ no_____ If yes, please
explain: ________________________________ Do you take medications on a routine basis?
yes _____ no_____ If yes, please list:
___/___/___/ - ___/___/___/ - ___/___/___/___ ___/___/___/ -___/___/___/ - ___/___/___/___ Have you been to the dentist in the past year? yes _____ no_____ If yes, dentist name:
Subscriber’s Date of Birth (month / day / year) Race: Please check all that apply (Optional)
3 Asian; 4 Native Hawaiian/Pacific Islander Other: __________________________________

Source: http://mvhealthcareaccess.org/pdf/Vineyard_Smiles_Senior_Dental_Clinic_Form.pdf