PARENT / GUARDIAN (Complete if patient is under 18 years old)
EMERGENCY CONTACT (In an emergency, the person listed below will be told that you are receiving care at our practice.)
By providing your household size and income, you will help us meet requirements of the federal and state grants that we receive. This enables us to continue providing care for everyone in our community.
Please enter your household size and annual gross household income in the space provided.
Thank you for your participation.
To apply, please provide the information below for everyone in your household, and attach proof of income.
PLEASE NOTE: You must submit proof of income within 30 days from the date of service or the date on this form. We will then determine your discount, which will be in effect for one year. Please provide proof of each type of income that any member of your family receives.
These are accepted proofs of income:
The above information supplied is current and accurate to the best of my knowledge. I understand that if information provided is found to be inaccurate, any discount given may be reversed.
Greater Seacoast Community Health (including Goodwin Community Health, Families First Health Center and Lilac City Pediatrics) asks our patients to understand and agree to the information in this document. More information is available in separate documents, as noted below. If you have questions about any of this information, please ask our office staff.
General Consent for Outpatient Diagnosis, Care and Treatment
Confidentiality, Privacy and Disclosure of Health Information
Behavioral Health Services
Achieving a Strong Patient-Provider Team Partnership
We value the relationships we build with our patients. Building this partnership between you and your provider team begins with mutual trust and respect.
You can expect us to:
We expect you to:
Financial Responsibility Agreement and Assignment of Benefits
Please read these three documents, which are available upon request from office staff and also at GetCommunityHealth.org/patient-info/
I understand the information contained in this Informed Consent document. I agree to the conditions set forth in the Informed Consent and in the other documents referenced above. Any questions I had about this consent have been answered. This consent will remain in effect unless I revoke it in writing, which I may do at any time.
What is your height? blanks What is your weight? blank
If female, are you pregnant? Please SelectType Option 1Type Option 2Type Option 3 nursing? Please SelectType Option 1Type Option 2Type Option 3 taking contraceptives? Please SelectType Option 1Type Option 2Type Option 3
Please check box next to any health conditions that you have, or have had, and write in details.
High blood pressure Heart issues: heart attack, coronary artery disease, endocarditis, heart murmur/defect, pacemaker, artificial heart valves, surgery, other: High cholesterol Current or past history of alcoholism, drug addiction, recreational drug use: Breathing issues: asthma, COPD, emphysema, chronic bronchitis, other: Tuberculosis or positive TB skin test Digestive issues: GERD/reflux, Crohn’s disease, IBS, ulcers, surgery Stroke. If yes, when? Immune issues: HIV/ AIDS, auto-immune disorders, other Liver issues: hepatitis A, B, C, D, E, cirrhosis, fatty liver disease, other: Type a labelCold sores (Herpes Simplex I) ADHD / ADD Issue with blood/bleeding/clotting: hemophilia, anemia, factor V Leiden, other Thyroid problem Cancer or tumor (current or past) Diabetes (type I, type II). If yes, what was your last HbA1c score? When was it done? Neurological problems: epilepsy/seizures, neuralgia, other: Mental health issues: anxiety, depression, bi-polar disorder, schizophrenia, other: Kidney problems: kidney failure, stones, other: Type a label Taken bisphosphonates (Ex. Boniva, Foxamax, Actonel, Atelvia, Reclast etc.) Disability (physical or mental that may require accommodation) Type a label Sleep apnea or snoring Artificial Joints Dry mouth Any medical issues not addressed above? Type a label
Do you use tobacco? Please SelectYesNo If yes, how much? blanks If yes, how motivated are you to quit? Please Select1 low motivation23 45678910 high motivation Do you drink alcohol? Please SelectYesNo If yes, about how many drinks per week? Type a label Do you drink any of these regularly ? Fruit juice Soda Energy drinks Coffee or tea with sugar What is your daily oral hygiene routine? Type a label
I consent to be a patient at Greater Seacoast Community Health Dental Center and agree to a radiographic and clinical examination. I also understand and consent to the following:
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I am signing below that I have read and understood this form.
I authorize Greater Seacoast Community Health to obtain the patient's personal health information from the following facility or person for the purpose of transferring care.
Please INITIAL all types of information that you authorize us to release or obtain:
Methods of Disclosure Authorized: Faxed, written, phone conversation, in-person and/or secure e-mail.
Patients are financially responsible for services provided by our office. Greater Seacoast participates with a number of insurance companies and will bill to all insurances.
For your convenience, our office will try to verify your insurance benefits for you. However, ultimately it is the patient’s responsibility to determine benefit and authorization information with your insurance company before services are provided. Please note that verification of benefits is not a guarantee of payment. Your insurance company makes the final determination.
Patients are fully responsible for payment for services not covered by their insurance.
Greater Seacoast strongly recommends that you have us submit a pre-treatment estimate to your insurance company before services are provided. Without this, we can only estimate your portion of the visit. Due to insurance companies’ limitations on the frequency of services, waiting periods, and maximum allowable charges, there is a chance your services may not be covered if a pre-treatment estimate is not submitted before services are rendered.
Please sign below that you have read and understand the above statement