Re-Enrollment Packet English | Family Development Services

Marion County Public Health Department Client Registration Form

Please complete this form so we can provide the best care possible. The information you share with us is part of your confidential medical record. Some infectious diseases must be reported to the Indiana State Department of Health in accordance with Indiana state law (IC 16-41-2-1).

Birth Date*

Child's Name*

First Middle Last

Nickname, other names used:*

Maiden:*

Address*

Street Address City State ZIP Code

Phone Number*

Email address*

Sex/Gender*

Male
Female
Trans (Male - Female)
Trans (Female - Male)

Marital Status*

Primary Language*

English
Spanish

Is the patient of a multiple birth? (twin, triplet, etc.) Check the box if the answer is Yes

Yes

Please answer both questions: Please select all that apply. (This information is for statistical use only)

1. What is this person’s race?*

2. Is this client Hispanic/Latino?

Insurance Information

Medicaid/Hoosier Health Wise ID#*

Dental Insurance

Company*

ID#*

Subscriber#*

Medicare ID#*

Other Medical Insurance

Company:*

Policy#*

Smoking Status (Select one if over the age of 12)*

Current Smoker
Former Smoker
Never Smoked

Parent or guardian information (if under age 18)

Name*

First Middle Last

Date of birth:*

Relationship*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

In case of emergency, who should be contacted?*

Phone Number*

Acknowledgement of receipt of Notice of Privacy*

I have received a copy of this office’s Notice of Privacy Practices. (You may refuse to sign this acknowledgement)

Authorization for Services*

I hereby authorize the Marion County Public Health Department to examine, test or provide services to the patient listed above. Test results and treatment will be explained to me as part of my visit today. If follow-up is needed or any test/exam results or appointment reminders, I will be contacted by a staff member.

Patient/Parent/Guardian signature:*

Date*

Name*

First Middle Last

Date*

MCPHD#*

Please check any of the following, which the patient has had or has currently:*

1. Have you ever received any health-related service from the Marion County Public Health Department?*

Yes
No

2. Do you have any diseases, conditions or problems not listed above?*

Yes
No

3. Are there any activities in gym class, athletics or other physical activities restricted in any way?*

Yes
No

4. Are you presently taking any medicine or drugs?*

Yes
No

5. List medication(s), dosage and directions*

6. Are you now or have you been under the care of a physician during the last two years?*

Yes
No

7. Have you ever been hospitalized or had surgery?*

Yes
No

8. Are you allergic to latex?*

Yes
No

9. Are you allergic to any medicine, drug or other substance?*

Yes
No

If “yes”, please list:*

10. Have you ever had a reaction to local anesthetic?*

Yes
No

11. Have you ever had a prolonged or unusual bleeding?*

Yes
No

12. Have you ever had complications or illness following dental treatment?*

Yes
No

13. Have you ever had any injury or trauma to your face or jaw?*

Yes
No

14. Do you smoke or use smokeless tobacco?*

Yes
No

15. Are you nervous or concerned about having dental work done?*

Yes
No

16. Women: Are you pregnant?*

Yes
No

Women: Do you use birth control?*

Yes
No

Women: Do you anticipate becoming pregnant?*

Yes
No

Women: Have you had any complications or problems with previous pregnancies?*

Yes
No

17. Do you presently have a dentist?*

Yes
No

Dentist’s Name*

Address*

18. Are you having dental pain or discomfort at this time?*

Yes
No

19. Why are you seeking dental treatment?*

*

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in my health, or if my medicines change, I will inform the doctor at the next appointment. Specific dental procedures will be explained to me. I understand that I/my child may not be able to receive all of the desired services from the Marion County Public Health Department and my treatment may require the need for me to be referred to other dental practitioners due to the nature of my dental problem. I understand that all dental procedures have benefits as well as certain risks, including possible side effects from some medicines used in dentistry and that these risks include, but are not limited to allergic reactions, cuts/ abrasions, tenderness/bruising from injections, sensitive teeth, swallowing inhaling dental materials/prosthesis and infections or serious complications or conditions.

Patient/Parent/Guardian signature:*

Date*

*

I also authorize and agree that the Health and Hospital Corporation of Marion County may keep or compile health information in any manner and is hereby authorized to use any treatment records, x-rays or photography for teaching or research purposes, including scientific journals or government-related publications. Patient confidentiality will be protected. Patient’s name or other private identifying information will not be released.

*

I hereby authorize insurance benefits to be paid directly to the dentist or their representative (Health and Hospital Corporation). I also authorize the dentist or other appropriate staff or representative to release information required to process claims and agree that a photocopy of this authorization is as valid as the original. I also agree that the Marion County Public Health Department may release a copy of my medical/dental record, or any portion thereof, or other information to the health professionals involved with my medical/dental care.

Signature*

Date*

Child's Name*

First Middle Last

Date of Birth*

Please list everyone that lives with you

Name	Birthday	Relationship	Gender	School	(Staff Use) MCPHD#

PATIENT CONTACT AUTHORIZATION

The Marion County Public Health Department allows you to request to receive communications regarding appointments, lab results, treatment and/or other health information. Please check all that apply:

I do not want any contact made.

Telephone Communication

Home Phone*

*

OK to leave a detailed voicemail message
Leave message with call back number only
Do not leave a message

Cell Phone*

*

OK to leave a detailed voicemail message
Leave message with call back number only
Do not leave a message

Work Phone*

*

OK to leave a detailed voicemail message
Leave message with call back number only
Do not leave a message

Other Phone

OK to leave a detailed voicemail message
Leave message with call back number only
Do not leave a message

Okay to leave a message with:

First Last

Relationship

Written Communication

You may contact me by mail using my home address
You may contact me by mail using my work/office address

If you have any other special request, please list:

Signature*

Date*

If you change your mind after completing this authorization, you must submit a written cancellation of the authorization. This will not affect or undo any disclosure prior to this notification.

Dear Parent or Guardian: The Marion County Public Health Department (MCPHD) Smile Mobile will be visiting your child’s school soon. The Smile Mobile is a forty foot, fully equipped dental office that comes complete with a reception/education area, a two chair dental treatment area, and a complete lab/ sterilization area. The Smile Mobile provides a mobile dental office for all children ages 18 and younger. Our goal is to provide a positive dental experience and an opportunity for better oral and overall health for your child. The MCPHD Smile Mobile is staffed by a highly qualified, professional and friendly dental team from the Marion County Public Health Department. The safety of your child is assured by ethical standards of practice by staff and dental services that are provided in a safe, sterile and pleasant environment. All dental instruments are sterilized or disposed of after each patient. The MCPHD Smile Mobile provides dental examinations, x-rays, cleanings, fluoride treatments and dental education during your child’s visit. If time allows, dental sealants are also provided. Your child will be encouraged to brush and floss daily to maintain a healthy smile and teeth. After the visit, a dental report from the dentist will be sent home with your child. The report will inform you on what treatment was provided and what further treatment is recommended. You will also receive a MCPHD Dental Services brochure listing MCPHD dental clinics where your child can receive further recommended treatment or you may seek treatment at a dental office of your choice. The dentist will contact you immediately regarding any urgent or emergency recommended treatment. There is an administration fee of $20 for your child’s dental visit. Medicaid and personal insurance reimbursement are also accepted as payment. Please be sure to include your child’s Medicaid or your personal insurance information with the attached registration and treatment consent form. If you do not have Medicaid or personal insurance for your child, a mail-in payment request for the $20 fee and a blue, self-addressed, return envelope will be sent home with your child. Money will not be collected at the visit. If you would like for your child to receive dental services from the MCPHD Smile Mobile, please fill out, in full, the attached form regarding your child’s medical history, family physician and a telephone number where you (or other adult family member) can be reached during the school day. Please sign the form and return it to your child’s school immediately. Please do not send money with the form or your child. We look forward to serving your child’s dental health needs! Sincerely, The MCPHD Smile Mobile Dental Team * In order for your child to receive services, please answer all questions in ink and return this completed form to your child’s school.

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