North Dallas Shared Ministries
Dental Clinic
2875 Merrell Rd
Dallas, Texas 75228

Patient Information Form

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NORTH DALLAS SHARED MINISTRIES - DENTAL CLINIC

Patient Information

Name(Required)

First Middle Name Last Name

Date of Birth:(Required)

Sex (M/F):(Required)

Language:(Required)

Address(Required)

City:(Required)

Zip Code - You must live in our service area. If you do not you may call 211 to get name of organization in your area.(Required)

Phone #(Required)

Type of phone:(Required)

Consent to text:(Required)

Email Address:(Required)

Race:(Required)

Ethnicity:(Required)

Number of People in Household:(Required)

Annual Household Income:(Required)

Below $ 12,140

$12,140-$16,460

$16,461-$20,780

$20,781-$25,100

$25,101-$29,420

$29,421-$33,740

$33,741-$38,060

$38,061-$42,380

$42,381-$46,700

$46,701-$51,020

$51,021- or higher

Emergency Contact Name:(Required)

Phone(Required)

Relationship to Patient(Required)

Do you have insurance?:(Required)

Do you have Parkland Plan?:(Required)

Signature

Date of Signature:(Required)

North Dallas Shared Ministries Medical History

Patient Name:

Date of Birth:(Required)

North Dallas Shared Ministries

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, can effect your treatment.

Are you under a physician's care now?

Yes

If Yes

Have you ever been hospitalized or had a major operation?

Yes

If Yes

Have you ever had a serious head or neck injury?

Yes

If Yes

Are you taking any medications, pills, or drugs?

Yes

If Yes

Do you take, or have you taken, Phen-Fen or Redux?

Yes

If Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes

If Yes

Are you on a special diet?

Yes

If Yes

Do you use tobacco?

Yes

If Yes

Do you use a controlled substance?

Yes

If Yes

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking Oral Contraceptives?

None of the above

Are you allergic to any of the following?

Aspirin

Penldllin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other

None of the above

If you chose other on allergic please list:

Do you have, or have you had, any of the following?

Please select all that apply to you.

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores/Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

None of the above

Please select all that apply to you.

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart Pacemaker

Heart Trouble/Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problem

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

None of the Above

Please select all that apply to you.

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Perathyroid disease

Psychiatic Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

None of the above

Have you ever had any serious illness not listed above?

Yes

If Yes:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent or Guardian:

Date of Signature:(Required)

NORTH DALLAS SHARED MINISTRIES

PATIENT UNDERSTANDING & INFORMED CONSENT FORM

Today's Date:(Required)

Patient Name:(Required)

First Middle Last

Date of Birth:(Required)

GENERAL INFORMATION: NDSM Dental Clinic has collaborated with Texas A&M College of Dentistry to provide dental treatment to patients of NDSM. Texas A&M College of Dentistry is a teaching institution and as such dental treatment will be provided by dental students with supervising dental faculty from the college. Dental treatment will meet or exceed the standard of care in dental schools and will be provided in a considerate, respectful and confidential manner. However, such treatment may require more time than if performed by a private dentist and appointments may be three hours or longer. Agape maintains current policies including but not limited to, blood borne and infectious diseases and radiation safety.

EMERGENCY DENTAL CARE: Emergency dental treatment is intended to provide relief of severe pain and infection for individuals in acute need. You as a patient have access to emergency dental care Monday through Friday from 8 AM until 5 PM l3ased on availability of students and faculty in accordance with the clinic schedule for that day.

CONSENT TO DENTAL PROCEDURES: As a patient you will at all times have access to current and complete information about your condition and will, unless otherwise specified, receive continuity of treatment and receive dental care according to a properly sequenced plan of treatment. Before receiving treatment, you should ask the student dentist or hygienist about the procedures that he/she recommends you undergo and ask any questions you may have before you decide whether or not to give your consent for the procedure(s) to be done. All dental procedures may involve risks of unsuccessful results and complications, and no guarantee is made as to result or cure. You have the right at all times to be informed of any such risks as well as the nature of the procedure, the expected benefit, the availability of alternative methods, of treatment, and the risks of no treatment. You have the right to consent to or refuse any proposed procedure at any time prior to its performance.

XRAYS: Dental radiographs will be made as necessary and appropriate for examinations, diagnosis, consultation, and treatment.

DENTAL MEDICAL RECORDS: The dental medical records, radiographs, (x rays), photographs, videos, models and other diagnostic aids relating to your treatment are the property NDSM. You have the right to inspect such materials and to request a copy of your dental medical records and radiographs. You may also request to have your dental radiographs sent to another health care provider by signing a Release of Information form. In addition, your dental medical record may be used for instructional purposes and if it is, your identity will not be disclosed to individuals not involved in your care and treatment.

KEEPING YOUR APPOINTMENTS: You are beguiled to be on time for- your appointments. If you find that you are unable to keep your appointment, you agree to notify the clinic 24 hours in advance. A total of two cancellations without 24 hour notice, two missed appointments, or repeated unsuccessful attempts to arrange appointments may cause serious delays in treatment and can result in discontinuation of care.

DISCONTINUANCE OF TREATMENT:NDSM reserves the right to discontinue dental treatment at any time. Your signature on this form certifies that you have read and understand the Information provided on the form, that you have received a copy, and that you accept dental care and treatment under the described terms and conditions.

Signature

Relationship:

Date of Birth:(Required)

Witness Signature:

You can upload required documents now or bring them with you to your appointment.

Photo ID

Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 100 MB.

Utility Bill - proof of residency

Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 100 MB.

By submitting your mobile number, you agree to receive text messages from NDSM. You can opt-out anytime. Message and data rates may apply.
Updated 8.24.2023.

North Dallas Shared Ministries Dental Clinic 2875 Merrell Rd Dallas, Texas 75228

Patient Information Form

NORTH DALLAS SHARED MINISTRIES - DENTAL CLINIC

Patient Information

North Dallas Shared Ministries

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, can effect your treatment.

Do you have, or have you had, any of the following?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status.

NORTH DALLAS SHARED MINISTRIES

PATIENT UNDERSTANDING & INFORMED CONSENT FORM

You can upload required documents now or bring them with you to your appointment.

North Dallas Shared Ministries
Dental Clinic
2875 Merrell Rd
Dallas, Texas 75228