1. Healthcare

FREE Dental Care
Ages 4 to 17
Saturday, October 11, 2014
Located at Fresno State South Gym
Your child’s overall oral health will be assessed and
dental services provided from cleanings to fillings
Pick up your medical history forms at the
Ted C. Wills Community Center
770 N. San Pablo Ave, 93728
Monday thru Friday from 10 am to 1 pm
Space is Limited– Sign up NOW!
Call 559-621-PLAY for more info
WAIVER, RELEASE AND INDEMNITY AGREEMENT
FOR ______Team Smile 2014______
For and in consideration of permitting _____________________ (print participant name) to
participate in Team Smile and those activities, operations and/or functions associated with the
event, in the City of Fresno, County of Fresno, and State of California, beginning on _Saturday,
October 11, 2014 and ending on _Saturday, October 11_, 2014 the Undersigned hereby voluntarily
releases, discharges, waives and relinquishes any and all actions for personal injury, property
damage or wrongful death occurring to him/herself arising as a result of observing, participating
and/or engaging in activities, operations and/or functions or any incidental thereto wherever or
however the same may occur and for whatever period said activities of Team Smile ( event) may
continue, and the Undersigned does for him/herself, his/her heirs, executors, administrators and
assigns hereby release, waive, discharge and relinquish any action or causes of action, aforesaid,
which may hereafter arise from him/herself and for his/her estate, and agrees that under no
circumstances will he/she or his/her heirs executors, administrators and assigned prosecute, present
any claim for personal injury, property damage or wrongful death against the City of Fresno and the
Fresno County Office of Education or any of its officers, agents, servants, or employees for any of
said causes of action, whether the same shall arise by the negligence of any said persons, or
otherwise. IT IS THE INTENTION OF ______________________________ (print participant name)
BY THIS INSTRUMENT, TO HAVE AGREED TO THE ASSUMPTION OF THE RISK AND TO
EXEMPT AND RELIEVE THE CITY OF FRESNO AND THE FRESNO COUNTY OFFICE OF
EDUCATION, OR ANY OF ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES FROM
LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH SUFFERED
BY UNDERSIGNED CAUSED BY PASSIVE OR ACTIVE NEGLIGENCE.
The Undersigned, him/herself, his/her heirs, executors, administrators or assigns to hold harmless,
indemnify and defend the City of Fresno, its officials, members, agents and employees against any
claims, costs, damages, demands, liability and notices, or any of these, liability and notices, arising
out of performance under this agreement regardless of whether the City of Fresno is actively
negligent or passively negligent, except for those claims, costs, damages, demands, liability and
notices, or any of these, caused solely by the negligence or willful misconduct of the City of Fresno.
Additionally, the undersigned voluntarily consents to use of Participant’s photograph, name, image
and likeness (Recordings), and waives and releases City of Fresno from any and all claims, causes,
damages, liabilities and/or actions arising there from and/or relating thereto, whatsoever, provided
said use shall be for non-commercial purposes in connection with advertising, administrative,
programmatic and promotional activities and materials. In connection therewith, Participant grants a
royalty-free, irrevocable permission to use, reproduce, publish, broadcast and distribute the
Recordings.
The Undersigned acknowledges that he/she has read the foregoing two paragraphs, has been fully
and completely advised of the potential dangers incidental to engaging in the activity, operation
and/or function, and is fully aware of the legal consequences of signing the within instrument.
__________________________________
Signature of Participant
______________________
Date
__________________________________
Signature of Parent or Guardian
___________________________________
Telephone Number (in case of emergency)
______________________
Date
Rev. Jan 2014
Health History and Consent for Dental Treatment
Please complete this form and sign as parent or guardian.
“TeamSmile” will provide free dental care and preventative care – including, but not limited to,
diagnostic exams, x-rays, professional cleanings, sealants, fillings, extractions, pulpotomies, crowns, and each
child will be educated on the value of the life-long commitment to oral health care.
Who Referred You/How Did You Hear About Us? (Identify the friend, school, church, organization):
Name:____________________________________________________________________________
To Be Completed by Parent or Guardian – Information about your child
Child’s Name: First__________________MI____ Last___________________________________
Child’s Date of Birth: ________________________ Child’s Gender: Male ____ Female______
Home Address____________________________________________________________________
City:___________________________________State_________ZIP_________________________
Home Phone _______________________
*Race/Ethnicity_____________________________
*(this information is used for future funding of TeamSmile programs)
Name of Parent/Guardian:_________________________________________
*Marital Status:  Married  Single  Divorced  Separated  Widowed
*House Hold Income:___________________________ *Number of members in the Household:__________
*(this information is used for future funding of TeamSmile programs)
Child Lives With:
□ Check if same as above
Name: First:__________________________MI______Last__________________________________________
Address:___________________________________________________________________________________
Home Phone:___________________________________Cell Phone:___________________________________
IN CASE OF EMERGENCY CONTACT on the day of service at the clinic:
1.
Name: ________________________________________________________________
Phone: __________________________
2.
Name: ________________________________________________________________
Phone: __________________________
I give consent for my child to participate in the preventive and restorative dentistry program conducted by the nonprofit organization,
TeamSmile. To the best of my knowledge, the medical history questions on page 2 have been answered correctly and accurately. I allow
my child to receive local anesthetic (numbing of the teeth), dental treatment, and to be photographed while at the clinic, understanding
that the photos may be used in future educational material. Our dental clinic will honor the rights of patients regarding their protected
health information with rare exceptions that must use and disclose only as much information needed to accomplish the intended dental
treatment.
Name of Parent/Guardian (Printed) _____________________________________________
Signature ____________________________________________ Date _________________
1 of 2 on 8/22/2014
Revised 5/24/2012
Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of
your entire body. Health problems that your child may have, or medication that your child may be
taking, could have an important interrelationship with the dentistry your child will receive. Thank you
for answering the following questions.
Is your child under a physician’s care now?
○ Yes ○ No
If yes, explain______________________________________
Has your child been hospitalized ?
○ Yes ○ No
If yes, explain______________________________________
Has your child had a major operation?
○ Yes ○ No
If yes, explain______________________________________
Has your child had a serious neck or head injury?
○ Yes ○ No
If yes, explain______________________________________
Is your child taking any medications, pills or drugs?
○ Yes ○ No
If yes, explain______________________________________I
Is there anything else we should know about the health of your child? List below:
___________________________________________________________________________________________________________________________
Is your child allergic to any of the following:
□ Aspirin
□ Penicillin
□ Codeine
□ Acrylic
□ Metal
□ Latex
□ Local Anesthetics
□ Other If yes, please explain_________________________________________________________________________________________
Does your child have, or have they had, any of the following?
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AIDS/HIV Positive
Anemia
Angina
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Hives or Rash
Ear tubes
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Chest Pains
Cold/Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/dizziness
Frequent Cough
Frequent Diarrhea
Renal Dialysis
Recurrent ear infections
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Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack
Heart Murmur
Heart Pace Maker
Heart Trouble
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Ulcers
Hearing loss
Has your child ever had any serious illness not listed above? ○ Yes
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Irregular heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Rheumatic Fever
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Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Yellow Jaundice
○ No If yes, please explain:________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
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To the best of my knowledge, the questions on this Medical History Form have been accurately answered. I
understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to
inform TeamSmile of any changes to my child's medical status.
Signature of Parent/Guardian______________________________________Date:______________________
2 of 2 on 8/22/2014
Revised 5/24/2012
Historia de Salud y el Consentimiento para el tratamiento dental
Por favor, rellene este formulario y firmar como padre o guradián.
"TeamSmile" brindará atención dental gratuita y la atención preventiva - incluyendo, pero no limitado a,
Los exámenes de diagnóstico, rayos X, limpiezas profesionales, selladores, empastes, extracciones, pulpotomías, coronas, y cada niño
será educado en el valor del compromiso de por vida a la atención de la salud oral.
¿Quién le refirio / ¿Cómo supo de nosotros? (Identificar el amigo, escuela, iglesia, organización):
Nombre: ____________________________________________________________________________
Para ser completado por el padre o tutor - Información acerca de su hijo
Nombre del niño: Primer Nombre__________________Segundo Nombre____ Apellido____________________________
Fecha de Nacimiento del Niño: ________________________
Sexo: Masculino ____ Femenino______
Dirección____________________________________________________________________
Ciudad: ___________________________________Estado_________Codigo Postal_________________________
Teléfono de casa _______________________ * Origen Étnico_____________________________
* (Esta información se utiliza para la futura financiación de los programas de TeamSmile)
Nombre del padre / guardián: _________________________________________
* Estado civil: □Casado □Soltero □Divorciado □Separado □Viudo
* Ingresos del hogar: ___________________________ * El número de miembros en el hogar: __________
* (Esta información se utiliza para la futura financiación de los programas de TeamSmile)
El niño vive con: □ Comprobar si es el mismo que arriba
Nombre: Primer Nombre:______________________Segundo Nombre ______Apellido_____________________________
Dirección: ___________________________________________________________________________________
Número del Teléfono:___________________________________Número del Celular: ______________________________
EN CASO DE CONTACTO DE EMERGENCIA en el día de servicio en la clínica:
1. Nombre: ________________________________________________________________
Número del Teléfono: __________________________
2. Nombre: ________________________________________________________________
Número del Teléfono: __________________________
Doy mi consentimiento para que mi hijo participe en el programa de odontología preventiva y restaurativa realizada por la
organización sin fines de lucro, TeamSmile. A lo mejor de mi conocimiento, las preguntas de la historia clínica en la página
2 se han respondido correctamente y con precisión. Yo permito que mi hijo reciba anestesia local (adormecimiento de los
dientes), el tratamiento dental, y para ser fotografiado, mientras que en la clínica, entendiendo que las fotos se pueden
utilizar en el material didáctico en el futuro. Nuestra clínica dental respeta a los derechos de los pacientes con respecto a su
información de salud protegida con raras excepciones que se deben utilizar y divulgar sólo la información que necesita para
llevar a cabo el tratamiento odontológico previsto.
Nombre del padre / guradián (imprenta) _____________________________________________
Firma ____________________________________________ Fecha _________________
1 de 2 el 8/22/2014
Revisado 5/24/2012
Historia Médico
Aunque el personal dental trata principalmente el área adentro y alrededor de la boca, tu boca es una parte de su cuerpo
entero. Los problemas de salud que tenga su hijo o los medicamentos que esté tomando podrían tener una interrelación
importante con el servicio dental que reciba. Gracias por contestar las siguientes preguntas.
¿Está su hijo bajo el cuidado de un médico ahora?
○ Sí ○ No
Si contestó “sí”, explique
¿Su hijo ha estado hospitalizado?
○ Sí ○ No
Si contestó “sí”, explique
¿Ha tenido su hijo una operación importante?
○ Sí ○ No
Si contestó “sí”, explique
¿Su hijo ha tenido una lesión grave
del cuello o de la cabeza?
○ Sí ○ No
Si contestó “sí”, explique
¿Está tomando su hijo medicamentos,
pastillas o drogas?
○ Sí ○ No
Hay algo más que deberíamos saber sobre la salud de su hijo? Escriba abajo:
Si contestó “sí”, explique
¿Es su hijo alérgico a algunos de los siguientes?
□ Aspirina
□ Penicilina
□ Codeína
□ Acrílico
□ Metal
□ Látex
□ Anestesias locales
□ Otro Si contestó “sí”, explique
¿Tiene su hijo o ha tenido alguno de los siguientes?
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Alergia al polen
Anemia
Anemia drepanocítica
Angina de pecho
Articulación artificial
Asma
Ataque cardíaco
Ataque cerebral
Cáncer
Convulsiones
Cortisona (medicamento)
Cuidado psiquiátrico
Culebrilla
Desmayos y mareos
Diabetes
Diálisis renal
Diarrea frecuente
Dolor en las articulaciones
de la mandíbula
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Dolores de cabeza frecuentes
Dolores de pecho
Enfermedad de la sangre
Enfermedad del hígado
Enfermedad del pulmón
Enfermedad estomacal/intestinal
Enfermedad paratifoidea
Enfermedad tiroidea
Epilepsia o convulsiones
Escarlatina
Espina bífida
Fiebre reumática
Hemofilia
Hepatitis A
Hepatitis B o C
Herpes
Herpes genital
Herpes labial/Boquera o calentura
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Hinchazón de extremidades
Ictericia
Infecciones del oído recurrentes
Leucemia
Marcapasos del corazón
Pérdida de la audición
Pérdida de peso reciente
Presión arterial alta
Presión arterial baja
Problema cardíaco
Problema de respiración
Problemas de riñón
Problemas de sinusitis
Prolapso de la válvula mitral
Quimioterapia
Ritmo cardíaco irregular
Sangrado excesivo
Se magulla fácilmente
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Sed excesiva
SIDA/VIH positivo
Soplo cardíaco
Tonsilitis
Tos frecuente
Transfusión de sangre
Trastorno congénito del corazón
Tratamientos de radiación
Tuberculosis
Tubos en los oídos
Tumores o bultos
Úlceras
Urticaria o sarpullido
Válvula artificial del corazón
¿Ha tenido su hijo alguna enfermedad grave no indicada en la lista arriba? ○ Sí ○ No Si contestó “sí”, explique:
De mi mejor conocimiento, las preguntas de esta Historia Médica fueron contestadas correcta y exactamente.
Entiendo que dar información incorrecta puede ser peligroso para la salud de mi hijo. Es mi responsabilidad
informar a TeamSmile de cualquier cambio en la condición médica de mi hijo.
Firma del padre, madre o guardián
Fecha:
2 de 2 el 8/22/2014
Revisado 5/24/2012