GIVE KIDS A SMILE DAY! - WED. FEBRUARY 19, 2020 - Touro College of ...
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GIVE KIDS A
SMILE DAY!
WED. FEBRUARY 19, 2020
JOINTLY ORGANIZED BY:
The enclosed forms are required in order for your child to receive
free dental care at this special event. Please complete and sign all
forms and bring them with you to your visit on Wed. February 19th.
Arrive promptly by 9:00 am to complete your child’s registration for
and participate in the fun activities planned prior to dental treatment.
If preferred, you may also return your completed forms in advance to:
EMAIL: dentalhealth@touro.edu | FAX: 914-594-2681Give Kids a Smile® at Touro College of Dental Medicine
CONSENT TO PARTICIPATE
Date of Event: 2/19/20
I give consent for my child, ________________________ to participate in the dentistry program
conducted through Touro College of Dental Medicine’s Give Kids a Smile (“GKAS”). To the best
of my knowledge, the medical history questions have been answered correctly and accurately. I
allow my child to have an oral screening, dental cleaning and fluoride treatment.
I understand my child might have certain medical conditions, which would keep him or her from
having dental treatment. I also understand that the dental care providers are volunteers, some
from local private practices.
I agree to seek any follow-up care that my child might need from my local dentist, health
department, or a hospital emergency room. For follow-up services, you also may call Touro
Dental Health at (914) 594-2700 or the Ninth District Dental Association at (914) 747-1199 who
will assist you with contact information for dentists in your area.
In consideration of any of the activities and free oral health care services received on
Wednesday, February 19, 2020, or any other date(s) of GKAS I, or myself and anyone entitled to
claim through me, do hereby waive and release from liability due to negligence and any other
causes arising out of participation in GKAS events wherever or however they occur and for such
period said activities may continue and agrees to release, defend, indemnify, and hold harmless
GKAS, its affiliates, employees, officers, event hosts, other participants, operators of any
premises used to conduct the event, and each of them, their officers, directors, employees and
their other agents (hereinafter called the “released parties”) from any and all liability that might
arise as a result of participation in any GKAS events.
I affirm that I clearly understand the risks associated with the event and that I am freely releasing
the released parties and their agents from all liabilities, claims, actions, damages, costs or
expenses of any nature arising out of or in any way connected with my participation or associated
with my injury or death arising out of or in connection with the event, even if said injury or death is
a result of negligence, active or passive, on their part, or arising out or related to claims of breach
of contract or strict liability. I affirm that I sign this document understanding that it might prevent
me from seeking damages. I also acknowledge that I shall adhere to all local laws then in effect
and am responsible for understanding such laws.
I hereby agree to indemnify and hold each of the released parties harmless from and against any
and all such liabilities, claims, actions, damages, costs or expenses including, but not limited to,
all attorneys' fees and disbursements up through and including any appeal.
I affirm that I am the parent or legal guardian of the minor named above and that I sign this
document on behalf of myself, all other parents or legal guardians, and the minor/ participant
and participant’s heirs, executors, administrators and assigns. I affirm that I understand that my
signature on this document prevents me for disavowing this waiver and prevents the minor from
disavowing this waiver, now or in the future.
__________________________________ ____________________________________
Name of Participant (please print) Name of Parent/Guardian (please print)
__________________________________ ____________________________________
Signature of Parent/Guardian DateGive Kids A Smile® at Touro College of Dental Medicine
PHOTO/VIDEO/SOUND RECORDING CONSENT AND RELEASE FORM
______________________
(Date of Event)
______________________
(Location of Event)
By signing this Photo, Video and Sound Recording Consent and Release Form (“Consent and
Release Form”), you are irrevocably giving permission to the ADA Foundation, the American
Dental Association, Touro College of Dental Medicine, and The Ninth District Dental Association,
collectively, the “Organizations” and individually, and their respective officers, agents, and
employees, to take and use photographs, video, and/or sound recordings (“Images”) of your child.
Granting this permission is completely voluntary on your part.
Your consent to the use of the Images, and your child’s image, likeness, appearance, and voice is
permanent. You will not receive compensation for the use of your child’s image, likeness,
appearance, and voice now or in the future. The Organizations may use the Images containing
your child’s image, likeness, appearance, and voice in any manner or media, including but not
limited to TV/video broadcast and internet/web. The Images may be used in whole or in part, alone
or with other recordings. The Images may be used for any educational, promotional, advertising,
fundraising, or commercial purpose, or any other purposes whatsoever. Any Organization has the
right and may allow others outside the Organization to copy, edit, alter, retouch, revise, and/or
otherwise change the Images at the Organization’s discretion. In addition, an Organization my
permit GKAS program sponsors to use the Images in furtherance of Give Kids A Smile. All right,
title, and interest in the Images belong solely to the Organization taking the Images.
I release each Organization and their respective officers, agents, and employees from any and all
liability which may or could arise from the taking, recording, publication, distribution, or other use
of photography and audio/video media.
___________________________________________________________________________
Name(s) of Child Covered by this Release (please print)
____________________________________ __________________________________
Name of Parent/Guardian (please print) Signature of Parent/Guardian
____________________________________ __________________________________
Address of Parent/Guardian DateTouro Dental Health
19 Skyline Drive, 3rd Fl., Hawthorne, NY 10532
914-594-2700
TOURO DENTAL HEALTH
PATIENT REGISTRATION FORM
PATIENT INFORMATION
TOURO DENTAL HEALTH
Last Name: First Name:
Street Address: Apt #:
City: State: Zip Code:
Primary Language: Date of Birth: Gender:
Email Address: Social Security #:
( ) - ( ) - ( ) -
Home Phone Work Phone Mobile Phone
Ethnicity: Marital Status:
Black/African American Asian Single Separated
Hispanic/Latino American Indian or Alaskan Native Married Widowed
White/Caucasian Native Hawaiian or other Pacific Islander Divorced
EMERGENCY CONTACT
Last Name: First Name: Relationship:
( ) - ( ) - ( ) -
Home Phone Work Phone Mobile Phone
PARENT OR GUARDIAN
Last Name: First Name: Relationship:
( ) - ( ) - ( ) -
Home Phone Work Phone Mobile Phone
INSURANCE INFORMATION
Insurance Company: Group #:
Policy Holder’s Name: Date of Birth:
Relationship to Patient: Self Spouse Parent Other: ______________________
OTHER COVERAGE
Additional Insurance: Yes No Insurance Company: Group #:
Policy Holder’s Name: Date of Birth:
Relationship to Patient: Self Spouse Parent Other: ______________________
PLEASE INDICATE HOW YOU HEARD OF TOURO DENTAL HEALTH
Newspaper Article TV Advertisement Radio Direct Mail/Postcard Brochure
Community Organization Website Family or Friend I am Faculty/Staff I am a Student
Referral from Doctor or Dentist (Name: ____________________________________) Other: _____________________________________
AUTHORIZATIONS
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist
or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your
use and disclosure of my protected health information to carry out payment activities in connection with this claim.
Patient/Guardian Signature: X ______________________________________________________________________ Date __________________
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Touro Dental Health.
Subscriber Signature: X __________________________________________________________________________ Date __________________Touro Dental Health
19 Skyline Drive, 3rd Fl., Hawthorne, NY 10532
914-594-2700
TOURO DENTAL HEALTH
Date (Fecha): / /
TOURO DENTAL HEALTH
CHILD & ADOLESCENT INTAKE QUESTIONNAIRE / CUESTIONARIO DE ENTRADA PARA NIÑOS Y ADOLESCENTES
Please fill out the following questions to the best of your knowledge in order to help us to provide safe and efficient dental care for your child.
Upon your initial visit additional questions may be asked. All information is completely confidential.
Por favor conteste estas preguntas a su mejor saber y entender para ayudarnos a brindar cuidado dental seguro y eficiente para su niño.
Después de su visita inicial, se pueden hacer preguntas adicionales. Toda la información es completamente confidencial.
GENERAL INFORMATION / INFORMACIÓN GENERAL
Child’s name (Nombre del niño) Preferred nickname (if applicable) (Sobrenombre preferido (si se aplica))
Child’s date of birth (Fecha de nacimiento del niño) Child’s gender identity (Identidad de género del niño) Child’s favorite hobby (Pasatiempo favorito del niño)
CHIEF COMPLAINT QUEJA PRINCIPAL
Why did you bring the child here today? (choose all that apply) ¿Por qué trajo al niño hoy al consultorio? (escoja todo lo que corresponda)
Check up – no specific problems Cavities Chequeo – no tiene problemas específicos Caries
Teeth cleaning Pain / discomfort Limpieza de dientes Dolor / molestia
Interested in braces Interesado en frenos dentales
Other concern(s) _______________________________________ Otra(s) inquietud(es): ____________________________________
________________________________________________________ ________________________________________________________
HEALTH AND MEDICAL HISTORY HISTORIAL DE SALUD Y ATENCIÓN MÉDICA
Please list child’s physician or medical facility: Indique el médico o clínica médica del niño:
Name: __________________________________________________ Nombre: _________________________________________________
Address: __________________________________________________ Dirección: _________________________________________________
________________________________________________________ ________________________________________________________
Phone: ___________________________________________________ Teléfono: _________________________________________________
Child’s weight (lbs.): ___________________ Peso del niño (libras): ___________________
Does child have a present or past history of any of the following? ¿Tiene el niño un historial actual o pasado de lo siguiente?
(choose all that apply) (escoja todo lo que corresponda)
Asthma Asma
Cancer Cáncer
Chemo/Radiation Therapy Quimioterapia/radioterapia
Diabetes mellitus Diabetes mellitus
Eating disorders Trastornos de la alimentación
Gastrointestinal problems (e.g. gastric reflux, frequent vomiting) Problemas gastrointestinales (ej., reflujo gástrico, vómitos frecuentes)
Heart murmur, or other cardiac defect, issue or disease S oplo cardíaco u otro defecto, problema o enfermedad del corazón
HIV VIH
Kidney disease Enfermedades del riñón
Liver disease Enfermedad hepática
Pulmonary disease Enfermedad pulmonar
Seizure disorder Trastorno convulsivo
Sickle cell anemia Anemia falciforme
Other: ________________________________________________ Otro: _________________________________________________
None of the above Nada de lo anterior
Has child ever experienced prolonged bleeding or trouble healing? ¿Ha tenido el niño alguna vez sangrado prolongado o problemas para cicatrizar?
Yes No Sí NoHas child ever undergone any of the following? (choose all that apply): ¿Ha pasado el niño alguna vez por lo siguiente? (escoja todo lo que corresponda): Overnight hospitalization(s) Surgical procedure(s) Noche(s) hospitalizado Procedimiento(s) quirúrgico(s) Does child have any allergies? (choose all that apply) ¿Tiene el niño alergias? (escoja todo lo que corresponda) Latex (i.e. rubber) Látex (ej., hule) Anesthetics (e.g. “Novocain”) Anestésicos (ej., “Novocaína”) Drug: ________________________________________________ Medicamento: __________________________________________ Food: ________________________________________________ Alimentos: ____________________________________________ Other: ________________________________________________ Otro: _________________________________________________ None of the above Nada de lo anterior Are child’s immunizations up to date? ¿Tiene el niño las vacunas al día? Yes No Sí No Does child have any of the following conditions? ¿Tiene el niño alguna de las siguientes condiciones? Trouble hearing Trouble seeing Problemas para oír Problemas para ver Speech delay Retraso en el habla Other: ________________________________________________ Otro: _________________________________________________ None of the above Nada de lo anterior Has child been diagnosed with any of the following developmental issues? ¿Se diagnosticó al niño con alguno de los siguientes problemas del desarrollo? ADHD Asperger Syndrome Déficit de atención e hiperactividad (ADHD) Síndrome de Asperger Autism Cerebral Palsy Autismo Parálisis cerebral Learning problems Trisomy 21 Problemas de aprendizaje Trisomía 21 Other: ________________________________________________ Otro: _________________________________________________ None of the above Nada de lo anterior Has child’s doctor or teacher ever recommended an evaluation for: Indique si el médico o el maestro del niño recomendó alguna vez una evaluación de: Occupational therapy Physical therapy Terapia ocupacional Fisioterapia Speech therapy None of the above Terapia del habla Nada de lo anterior MEDICATIONS MEDICAMENTOS Please list any medications the child is prescribed at this time: Por favor escriba los medicamentos que el niño tiene recetados en este momento: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Does child have a condition such as asthma, allergies or chronic ear ¿Tiene el niño una condición como asma, alergias o infecciones crónicas de infections that requires taking syrupy medications for prolonged periods of oído para la que toma jarabes durante períodos largos (al menos 3 veces time (at least 3 times per year)? por año)? Yes No Sí No Does child use an inhaler? ¿Usa el niño un inhalador? Yes No Sí No PAST DENTAL HISTORY HISTORIAL DENTAL PASADO Has child ever been to a dentist before today? ¿Fue el niño a un dentista antes? Yes No Sí No Age of child at first dental visit? ________________________________ ¿Edad del niño en la primera visita dental? ________________________ Age of child at last dental visit? ________________________________ ¿Edad del niño en la última visita dental? _________________________ Reason for last dental visit? ___________________________________ ¿Razón de la última visita dental? _______________________________ Were any x-rays taken? ¿Se tomaron rayos X? Yes No Don’t know Sí No No sé How was child’s behavior at last dental visit? ¿Cómo se comportó el niño en la última visita dental? Cooperative Apprehensive Uncooperative Cooperó Inquieto Poco cooperativo
FAMILY HISTORY HISTORIA FAMILIAR Who is primary caregiver for this child? ¿Quién es el cuidador principal de este niño? Mother Extended family member (e.g. aunt, grandparent) Madre Pariente cercano (ej., tía, abuelos) Father Group home attendant Padre Encargado de hogar comunitario Nanny/babysitter Foster parent Niñera/baby-sitter Padres de hogar de crianza Other: ________________________________________________ Otro: _________________________________________________ Does primary caregiver(s) have untreated dental decay (i.e. cavities)? Indique si las personas principales que cuidan al niño tienen caries dentales Yes No no tratadas. Sí No DIETARY HABITS HÁBITOS DE ALIMENTACIÓN Was or is child breast-fed? ¿Tomó o toma el niño leche materna? Yes No Sí No On demand (i.e. always available or in reach) A pedido (es decir, siempre disponible o al alcance) On schedule (i.e. at specific pre-planned times of day) Con horario (es decir, a horas del día específicas y preplaneadas) If applicable, at what age did breast-feeding stop? _______________ Si se aplica, ¿a qué edad dejó de amamantar? __________________ Was or is child bottle-fed? ¿Tomó o toma el niño biberón? Yes No Sí No On demand (i.e. always available or in reach) A pedido (es decir, siempre disponible o al alcance) On schedule (i.e. at specific pre-planned times of day) Con horario (es decir, a horas del día específicas y preplaneadas) If applicable, at what age did bottle-feeding stop? ________________ Si se aplica, ¿a qué edad dejó de tomar biberón? ________________ Which of the following does child currently use to drink beverages? ¿Cuál de los siguientes usa el niño actualmente para tomar bebidas? (choose all that apply): (escoja todo lo que corresponda): Bottle Drinking cup or glass Biberón Taza o vaso para beber Juice box/pouch Sippy or training cup Jugo de cajita/bolsa Taza para bebés o vaso entrenador Other: ________________________________________________ Otro: _________________________________________________ What type(s) of beverages does the child frequently consume? ¿Qué tipo(s) de bebidas toma el niño con frecuencia? (choose all that apply): (escoja todo lo que corresponda): Formula Soda Leche de fórmula Refrescos/soda Breastmilk Juice Leche materna Jugo Plain milk (e.g. cow’s, almond, soy) Sports drinks Leche común (ej., vaca, almendra, soya) Bebidas deportivas Flavored milk (e.g. vanilla, chocolate) Water Leche saborizada (ej., vainilla, chocolate) Agua Other: _______________________________________________ Otro: _________________________________________________ What type(s) of snacks does child frequently consume? ¿Qué tipo(s) de botanas come el niño con frecuencia? (choose all that apply): (escoja todo lo que corresponda): Yogurt Pretzels Chips Yogur Pretzels Papas fritas de bolsa (chips) Crackers Cereal Cookies Galletas Cereal Galletitas dulces Candy Ice cream/ices Fruit rolls/snacks Dulces Helado, nieve Rollitos de fruta/snacks Other: ____________________________________________ Otro: _________________________________________________ How many times per day does child consume snacks and/or beverages ¿Cuántas veces al día consume el niño snacks o bebidas entre las between meals? ____________ comidas? ____________ ORAL HYGIENE HABITS HÁBITOS DE HIGIENE ORAL When are child’s teeth brushed? (choose all that apply): ¿Cuándo le cepillan los dientes al niño? (escoja todo lo que corresponda): Never Morning Evening Nunca Mañana Noche Other times: ___________________________________________ Otras veces: ______________________________________________ Are child’s teeth flossed daily? ¿Le pasan el hilo dental al niño todos los días? Yes No Sí No Does caregiver assist child with brushing/flossing? ¿Ayuda el cuidador al niño a cepillarse/usar el hilo dental? Yes No Sí No What is child’s attitude toward tooth brushing/flossing? ¿Qué actitud tiene el niño al cepillarse los dientes/usar el hilo dental? Loves it Tolerates it Can’t stand it Le encanta Lo tolera No lo soporta
FLUORIDE HISTORY HISTORIAL DE USO DE FLÚOR
What kind of water does child drink? (choose all that apply) ¿Qué tipo de agua bebe el niño? (escoja todo lo que corresponda)
Tap - unfiltered Tap - filtered Bottled Well Agua de grifo - no filtrada Agua de grifo - filtrada
Agua embotellada Agua de pozo
Does child take a daily vitamin?
Yes No ¿Toma el niño una vitamina diaria?
With fluoride (requires prescription) Sí No
Without fluoride (over-the-counter) Con flúor (recetada) Sin flúor (sin receta)
Does child use an a mouth rinse daily? ¿Usa el niño un enjuague bucal todos los días?
Yes No Sí No
I With fluoride Without fluoride Con flúor (recetada) Sin flúor (sin receta)
Brand and type of toothpaste used: ______________________________ Marca y tipo de pasta dental que usa: ____________________________
TRAUMA HISTORY HISTORIAL DE TRAUMATISMO
Has child’s “baby teeth” ever experienced any injuries? ¿Tuvo alguna vez el niño lesiones en los “dientes de leche”?
Yes No Sí No
Has child’s “adult teeth” ever experienced any injuries? ¿Tuvo alguna vez el niño lesiones en los “dientes de adulto”?
Yes No Not applicable Sí No No se aplica
Has child ever experienced any other kind of oral-facial trauma? ¿Tuvo alguna vez el niño cualquier tipo de traumatismo oral y facial?
Yes No Sí No
BEHAVIORS COMPORTAMIENTOS
Does the child have a past or present history of the following habits? ¿Tiene el niño un historial pasado o actual de los siguientes hábitos?
(choose all that apply) (escoja todo lo que corresponda)
Pacifier Thumb or finger sucking Chupón (chupete) Se chupa el pulgar o dedo
Nail biting Tooth grinding Se come las uñas Aprieta/rechina los dientes
None of the above Nada de lo anterior
Does the child participate in any of the following activities? ¿Participa el niño en alguna de estas actividades?
Plays a brass or woodwind instrument Sports Toca un instrumento de viento (bronce o madera) Deportes
None of the above Nada de lo anterior
These questions only apply to children 12 years of age or older: Estas preguntas se aplican solo a los niños mayores de 12 años:
Does child use any of the following? (choose all that apply): ¿Usa el niño algunos de los siguientes? (escoja todo lo que corresponda):
Alcohol Birth control Alcohol Control de la natalidad
Cigarettes Vaporizers (e.g. vape pens, Juul) Cigarrillos Vaporizadores portátiles (ej., pluma, Juul)
None of the above Nada de lo anterior
Does child have any oral piercings? Yes No ¿Tiene el niño perforaciones en la boca? Sí No
Date of last menstrual period: ________________ Not applicable Fecha del último período menstrual: ________________ No se aplica
Please provide any comments or additional information you feel is important for us to know:
Por favor escriba algún comentario o información adicional que, en su opinión, es importante que sepamos:
I CERTIFY THAT ALL THE INFORMATION I HAVE PROVIDED IS TRUE TO MY KNOWLEDGE. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM TOURO
DENTAL HEALTH OF ANY CHANGES IN MEDICAL STATUS. CERTIFICO QUE TODA LA INFORMACIÓN QUE HE PROPORCIONADO ES VERDADERA A MI MEJOR
SABER Y ENTENDER. ENTIENDO QUE ES MI RESPONSABILIDAD INFORMAR A TOURO DENTAL HEALTH DE CUALQUIER CAMBIO EN EL ESTADO MÉDICO.
Name of person filling out this form (Nombre de la persona que llena este formulario) Relationship to child (Relación/parentesco con el niño)
Signature (Firma) Date (Fecha)
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