UMMC School of Dentistry Dental Mission Week 2020

February 3rd – 7th

Dear Applicant,

Thank you for your interest in our Dental Mission Week event. To apply for the free dental services that will be offered, please fully complete the attached forms and return them to this location before or no later than October 25, 2019.

If you are selected, you will be contacted and given a day and time to come to the UMMC School of Dentistry to be screened for treatment. If you do not receive a call by December 31, 2019, you were not selected. For your convenience, on your application please provide a working phone number by which you may be contacted.

Note: This event is for individuals who are uninsured and have limited to no access to dental care. If you DO NOT have an appointment time, you will not be seen. Please do not come to the School of Dentistry if you are not contacted with an appointment time. We will not be able to treat unscheduled walk-in patients.

For more information:

Call (601) 496-3232

https://www.facebook.com/School-of-Dentistry-at-UMMC

https://twitter.com/UMMC_Dentistry

Are you taking blood thinners? (i.e. Warfarin (Coumadin), Aspirin, Pradaxa, Xarelto, Plavix, or Other?___Yes___No

If Other, please name? ____________________________

If yes, what/when was the most recent INR? _____/_____

Are you or have you taken bone strengthening drugs? ___Yes ____No

Presently under a Physician's care? ____Yes ____No

Last Medical Visit: When _____Why?_________________ ________________________________________________ ________________________________________________

Are you a Veteran?____ Yes ____No

Dental Mission Week February 3-7, 2020

Current Current Medications

Urinary

___History of Kidney Disease

(List ALL medicines you are taking & dosage) (Time of last Dose)

______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________

__________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________

LAST Name (Apellidos):_________________________________________

Date of Birth (Nacimiento):_______________ Age (Edad): _____

Address (Direccion):_______________________________________________

City (Ciudad): ___________________________ State (Estado): _______

FIRST Name (Nombre):___________________________

Gender (Genero): ___F ___M

County (Condado):________________

Zip (Codigo Posta1):______________

Patient Information: Please Print & Sign Date: __________Phone No._____________________________Alternate Phone No.___________________

Health History(Check all that apply)

Cardiovascular___Heart Disease ___High/Low Blood Pressure ___Mitral Valve Prolapse ___Heart Murmur___Heart Valve Replacement ___Heart Stent ___Pacemaker

Digestive ___Ulcers/GERD ____Hepatitis

Ear/Nose/Throat___Hearing Loss

Endocrine ___Diabetes

Eyes ___Vision Loss___Wear Glasses/Contacts

Hematology/Lymphatic ___Anemia___Excessive Bleeding

Muscular/Skeletal

___Rheumatoid Arthritis ___Osteoarthritis ___Joint Replacement

Other___Organ Transplant

___Radiation Treatment

___Tobacco Use

Respiratory___Asthma___COPD___Chronic Bronchitis___Tuberculosis

Drug/Food Allergies___Latex Allergy ___Penicillin ___Sulfa___Other__________

__________ Immune

___HIV+/AIDS ___Lupus ___Scarlet Fever ___Rheumatic Fever

Nervous ___Seizures

For Office Use Only: MRN ____________________ Appointment: Date _______ Time _______

Chief Dental Needs: _________________________________________________

Important Notice

UMMC Dental Mission providers may not be able to provide you with all the services you need, but if you would like to consult with our team and receive the type of treatment being offered today, PLEASE READ THE PATIENT WAIVER BELOW VERY CAREFULLY.

Dental Patients Note: I understand that because of the number of people needing to be seen, I might not receive multiple extractions or multiple fillings. I understand that I might have certain medical conditions which would keep me from having the type of treatment I am requesting. I also understand that many of the dental care providers are volunteers, some from out of town, and are not available for follow-up care in the event of complications. Follow-up care is available through the School of Dentistry.

In consideration of the free dental care services received on the date below, I for myself and anyone entitled to claim through me, do hereby waive and release the University of Mississippi School of Dentistry, and any other organization or company or persons acting on their behalf or sponsoring or volunteering at this clinic, from all claims of liability arising out of my acceptance of such free care including but not limited to medical, surgical, dental, and/or vision care or other health care or medical advice.

I grant to the School of Dentistry at the University of Mississippi and its agents the right to use my picture, voice and other reproductions of my physical likeness in connection with advertising or publicizing UMMC Dental Mission Week services and its activities in all forms of media in perpetuity.

I have read, or had read to me, and understand and agree to all of the above.

_________________________________________________________ ________ Patient signature (parent or guardian if patient is under 18 years or age) Date

If under 18, please print guardian’s name

_________________________________________________________

Is guardian also receiving treatment today? Yes / No

If yes, name of Guardian: ___________________________________________