TRINITY DENTAL CLINIC
Medical History Form
NAME______________________________________________DATE OF BIRTH____________________
DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?
IN THE EVENT OF EMERGENCY, CALL_____________________________________________________
I GIVE PERMISSION FOR RELEASE OF DENTAL RECORDS TO:
Have there been any changes in your general health within the past
Have you ever had surgery of any type or been hospitalized for any
Are you taking or have you ever taken medications to treat
Osteoporosis or Padgett’s disease, such as Fosamax, Actonel, Skelid,
Boniva, Didronel, or Aredia? Are you taking or have you ever taken medications to treat bone
cancers or bone diseases such as Aredia or Zometa?
Are you taking any medicine(s) including non-prescription medicine?
Please list ALL medications you are currently taking:
Are you allergic to or have you had a reaction to:
List ALL medications you are allergic to:
Have you ever had any abnormal bleeding?
Do you use alcohol, cocaine, or any other drugs?
Are you pregnant or think you may be pregnant?
Do you have or have you had the fol owing: Rheumatic heart disease or rheumatic fever?
Do you have pain in your chest upon exertion?
Are you ever short of breath after mild exercise?
Do you ever get short of breath when you lie down?
Do you require extra pillows when you sleep?
Please list any disease, condition, or problem not listed above:
All of the above is true to the best of my knowledge. I grant permission for Trinity to request/release
any information including x-rays to/from other providers as necessary regarding my treatment.
PRINT PATIENT’S NAME____________________________________________________________
SIGN NAME _____________________________________________DATE____________________
PATIENT CONSENT FOR TREATMENT
I, the undersigned, am the patient, or the patient’s duly authorized representative, and do hereby
voluntarily consent to and authorize care and treatment by Trinity Health Ministries, through its
individual dentists, employees, and/or agents. This care and treatment encompasses all diagnostic
and therapeutic treatments considered necessary or advisable in the judgment of the dentist and
I am aware that the practice of dentistry is not an exact science and I acknowledge that no guarantees
have been made to me as to the result of treatments or examinations performed by the dentist or
I acknowledge that I have received a Copy of Trinity Health Ministries’ Notice of Privacy Practices and I
understand that the notice is also available at the location where services are provided.
To protect against the transmission of blood-borne diseases such as Hepatitis B and Acquired Immune
Deficiency Syndrome, I understand that it may be necessary to test my blood for certain diseases while
I am a patient of Trinity Health Ministries. I understand and consent that my blood, as well as the
blood of any person accidentally exposed to my blood, will be tested.
I HAVE READ THIS FORM, OR HAD IT READ TO ME, AND I CERIFY THAT I FULLY UNDERSAND AND
PRINT PATIENT’S NAME___________________________________________DATE____________
TRINITY DENTAL CLINIC
Trinity Health Ministries, Inc. (THM) is a non-profit organization and is NOT part of a government
program. THM focuses on urgent and emergent care for adults (age 21 and over) in Blount County
Tennessee who satisfy THM’s financial eligibility criteria. THM performs x-ray facilitated dental
exams and informs patients of treatment options, extractions (including surgical extractions),
aveoloplasties (ridge trims to facilitate denture wear), oral biopsies, incision and drainage (when
needed to manage oral infections), and dental prophylaxis (cleanings). Due to THM’s limited opening
hours, emergencies requiring treatment on non-clinic days will require treatment at alternative
facilities, such as a private dental office, emergency room, or physician’s office at the patient’s
In consideration of benevolent services that I receive at THM, I and anyone entitled to claim through
me, do hereby waive and release THM or any persons or organizations acting on their behalf, from all
claims of liability arising out of my acceptance of such benevolent care.
PRINT PATIENT’S NAME_________________________________________DATE_________________
TRINITY DENTAL CLINIC
PATIENT CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Read the fol owing statement:
PURPOSE OF CONSENT:
By signing this form, you will consent to our use and disclosure of your
protected health information to carry out treatment, payment activities, and healthcare operations.
NOTICE OF PRIVACY PRACTICES:
You have the right to read our Notice of Privacy Practices before
you decide whether to sign this Consent. Our Notice provides a description of our treatment,
payment activities, and healthcare operations, of the uses and disclosure we may make of your
protected health information, and of other important matters about the right to change our privacy
practices as described in our Notice of Privacy Practices. A copy of our Notices of Privacy Practices
accompanies this Consent. If we change our privacy practices, we will issue a revised Notice of
Privacy Practices, which will contain the changes. Those changes may apply to any of your protected
I have had full opportunity to read and consider the contents of this consent form. I understand
that, by signing this form, I am giving my consent to your use and disclosure of my protected health
information to carry out treatment, payment activities and health care operations.
I have received a copy of this office’s Notice of Privacy Practices.
I attempted to obtain written acknowledgement of receipt of Notice of Private Practices, but
acknowledgement could not be obtained.
At any time you have the right to revoke consent to disclose your healthcare information.
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