Oep4rtmenl of Oral & MaxllloflllClal Surgery
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ TOOAr5 DATE _
DATE OF BIRTH AGE _ SEX (CIrde) Male Fem_ REFERRED BY _
DESCRIBE WHY YOU CAME TO ntE DOCTOR TOOA Y:
All.EAGIES TO: HAVE YOU HAD ANY PREVK>U$:
YES NO YES NO YES NO
o 0 Penlc:IIlln o 0 Operations (Ust Below) o 0 Anesthesia Complications (ExJria!nl
D 0 Local AnestheSIa
D 0 Other
Ust All The MedlcatlonsJOrugs You Ale ClJITentIy Taldng
Primary MD Doctor '
c Phone ' -j
, , Primary Dentist: Phone:
• (Other Doctors)
, 7 D' specla,ty Phone' -l
• • 0,. Specialty Phone:
HISTORY OF l.LNeSSES:
Y. . No Y.. No Y.. No
........ Y.. No _........
o0 ey. f'r\:ltllernI
o 0 Ear Problems
o 0 SInuIT~
o 0 0emI PrcJbiernI;
o 0 Heart Trouble
CorQenbI HMrl DiseaM
Abnormal Hear'! Fttylm1
I'tgtl Blood Pressure
LDw Blood f>reaswe
o 0 Heart Attack o 0 Short'Iess 01 Brei" 0 0 s.,;~ 0 0 Clnoer Or To.morw
o 0 MgInII o 0 Lung Problems 0 0 Slroke 0 0 RlcIMIon T~t'nenl
o 0 Rheumatic Fever o 0 EmpllyMma 0 0 Prolonged Bleeding 0 0 Chernoltlerl~
0 0 Fr~nI Bruising 0 0 PsycNI1rIc IlrIeI_
Y.. No Yes No
DODo you have clicking or popping of jaw )oint, pain 1'1881 ear, DODo you wear contact lenses?
dltflculty opening mouth, grind or clench l"th? o 0 Have you ever laken aoculane?
DODo you smoke or use smokeless lobaooo? DODo you have any prosthellc joints?
o 0 Ale you on a special diel DODo you or any or your lamI)' members have Sickle cell
o 0 HI'" you taken slerolds INIthIn the last 3 monltls? Anemia or trail?
OntER ILLNESSES: WOllEN ONLY:
o 0 Ale you pregnant? DaM 01 last menstrual C)lde _
o 0 Ale you on bWth control?
Reviewed by Doctor: Code' Date Relllewed:
The University of Texas Health Science Center at San Antonio Dental School
CONSENT AND AGREEMENT FOR TREATMENT
Please read the following information carefully. After you have read this Consent and
Agreement, please sign your name below to accept the terms of this agreement.
1. Consent to treat: As a consenting adult, I agree to permit the students, faculty, staff and residents
of The University of Texas Health Science Center at San Antonio Dental School (UTHSCSA‐DS) to
provide dental care to myself, my child or patient representative as applicable.
2. Teaching facility: As a patient of UTHSCSA‐DS, all treatment will be provided by faculty or by
students or residents of the Dental School under the supervision of clinical faculty.
3. Limitations: Not all persons can be accepted as patients of UTHSCSA‐DS. Persons with complicated
medical conditions, rigid time requirements, and extremely difficult dental care needs may not be
accepted. I understand that if I am accepted as a patient, my treatment at the UTHSCSA‐DS may be
limited, after which time I would need to find dental care outside the Dental School. As a patient of
the UTHSCSA Dental Hygiene program, I understand that receiving dental hygiene care does not
guarantee future Dental School treatment.
4. Emergency care: Emergency treatment for relief of severe discomfort is available for non‐Dental
School patients, but during normal business hours only. The emergency treatment provided to
non‐Dental School patients does not mean that the Dental School will continue to provide further
5. Treatment Plan: Care and treatment at the Dental School takes longer than in a private dental
practice. Appointments may be up to four hours long, and I, the patient and/or the patient’s
representative must be prepared for multiple visits to complete my dental care needs.
6. Right to discontinue treatment: The UTHSCSA‐DS has the right to discontinue treatment for any
appropriate reason, such as, excessive cancellations. In such cases, the patient or patient’s
representative agrees to accept full responsibility for pursuing alternate professional dental care. A
letter will be sent informing the patient or patient’s representative that treatment is being
discontinued. All records pertaining to the treatment and diagnosis of patients are the property of
UTHSCSA‐DS. Records and x‐rays will be duplicated upon written request with a reasonable charge
to the patient.
7. Payment for services: I am expected to pay for the treatment I receive. UTHSCSA‐DS has the right
to revise fees at any time, for any procedure which has not yet been started. During the course of
my dental care, unexpected complications or new conditions may arise that may result in higher
cost. If my treatment becomes too complex for a dental student to manage, it may be necessary
for me to be referred to one of the specialty training programs to receive the care I need. Should
this occur, I understand that I will be expected to pay the specialty training program fee for the
8. Risks of treatment: The faculty at UTHSCSA‐DS is available to answer any questions concerning the
risks involved with specific procedures. All dental procedures have certain risks; including possible
side effects from some medicines used in dentistry. These risks include, but are not limited to:
a) allergic reactions b) cuts/abrasions c) tenderness/bruising d) sensitive teeth
07‐01‐06 Page 1 of 2
CONSENT AND AGREEMENT FOR TREATMENT
9. Follow‐up appointments: I understand that by accepting treatment at UTHSCSA‐DS I also consent
to future follow‐up appointments for the purpose of assessing the outcome of the dental treatment
provided to the patient.
10. Consent to photograph: I understand that photographs, videotapes, digital, and other images may
be recorded to document and assist with my care. These images may be used to assist in the
education of students and residents within the institution. I understand that UTHSCSA will own
these images, but that I will be allowed access to view them or to obtain copies of them at a
reasonable cost. Other than for treatment and education purposes, images that identify me will be
released and/or used outside the organization only upon written authorization from me or the
11. Notice of Privacy Practices: UTHSCSA may release information to other entities or health care
providers, for treatment, payment of services, and for health care operations as described in the
“Notice of Privacy Practices”. UTHSCSA has prepared this detailed document to help you better
understand our policies in regard to the use and disclosure of your personal health information.
I have been given the opportunity to review and receive a copy of the Notice of Privacy Practices.
Please initial: _____________
12. Research Study: If my oral health problems or treatment needs could possibly qualify me for a
clinical research study, I give permission for my information to be forwarded to the principle
Please initial: _____________
13. Consent to treatment: By signing below, I am indicating that I have read and I understand the
terms of the Consent and Agreement for Treatment. I am either the patient or have the authority to
give consent for the patient. I give consent to the UTHSCSA‐DS to perform necessary or appropriate
tasks for proper dental and physical examination, diagnosis, and treatment, including local
My questions regarding this consent and agreement have been answered.
Patient or Patient Representative Signature Date
If Patient Representative, Relationship to Patient Witness
07‐01‐06 Page 2 of 2