Health History Form

Patient Information (Please complete in ink)
Patient Name: _________________________________________________________ Date:_______________
Last First MI
Male Female Married Single Child Other________________
Birth Date: _____________________ ICCC ID # (must be included for free student services) ______________
Phone (with area code): _______________________________ Alternate # ______________________________
Address: __________________________________________________________________________________
Street City State Zip Code
Email: _____________________________________________________________________________________
Emergency Contact: (Name) ____________________________________ (Phone) _______________________
Ethnicity (optional): White, Non-Hispanic Hispanic American Indian/Alaskan Native
African-American Asian/Pacific Islander Other ______________________________
Health Information
Date of Last Dental Visit: __________________ Reason for this visit:_________________________________________
If you would like a copy of today’s x-rays sent to your dentist, please provide his/her name and address:
Dentist’s name:_______________________________ Address:_____________________________________________
Have you ever had any of the following? Please check those that apply:
Alcoholism
Allergies __________
__________
Anemia
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blood Disease
Cancer
Chemotherapy
Cortisone Medication
Diabetes
Dizziness
Dry Mouth
Eating Disorder
Emphysema
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
Heart Surgery
Hepatitis
High Blood Pressure
HIV/AIDS
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Pregnancy (currently)
Due date:_________
Previous Infective
Endocarditis
Recreational
Drugs/Cocaine
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sexually Transmitted
Disease (STD)
Sinus Problems
Stomach Problems
Stroke
Thyroid
Tuberculosis
Tumors
Ulcers
Codeine Allergy
Penicillin Allergy
Latex Allergy
OTHER:
Please list any medications you are now taking:______________________________________________________
____________________________________________________________________________________________
• Do you use tobacco products? Yes No If yes, what kind and how much? __________________
Are you interested in quitting? (Circle one) Very Somewhat Not interested
• Have you ever had to be pre-medicated for dental treatment? Yes No
• Have you ever had any complications following dental treatment? Yes No
If yes, please explain:_______________________________________________________________________
• Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
If yes, please explain:______________________________________________________________________
• Are you now under the care of a physician? Yes No
If yes, please explain:______________________________________________________________________
• Name of Physician:___________________________________________ Phone:______________________
• Do you have any health problems that need further clarification? Yes No
If yes, please explain:______________________________________________________________________
***********************************************************************************************************************************************************************************************************************************
I have reviewed the Health History and give permission for treatment to be completed by the Dental Hygiene
student
_________________________________________________________________ Date: ___________________
Signature of Clinic Dentist

Responsible Party Information
(Complete this section if patient is under 18 or someone other than the patient is responsible for payment)
The following is for: the patient's spouse the person responsible for payment the patient’s parent/guardian
Name:
Male Female Married Single Child Other
Birth Date: ______________________________
Phone (with area code): _____________________________Alternate#:
Mailing Address:
Street City State Zip Code
Insurance Information
Name of Insured: _______________________________________________ Is insured a patient? Yes No
Last First MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street City State Zip Code
Insured's Employer Name and Address
Patient's relationship to insured: Self Spouse Child Other___________________
Insurance Plan Name:_______________________________________________________________________
Address:
Street City State Zip Code
Dental Insurance: It is your responsibility to consult with your insurance company for details on your covered or non-covered services, service
limitations or restrictions, and yearly maximums. Medical coverage does not pay for dental hygiene services. You will receive a “super bill” that you can
send in for reimbursement from your insurance company.
Consent for Services
As a condition of your treatment by the Iowa Central Community College Dental Hygiene Student Clinic, financial arrangements must be made in
advance. The clinic depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each
patient must be determined before treatment. Payment for dental hygiene treatment is required at each visit. We accept cash, check, and credit cards
for payment of services.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally
responsible for payment of all dental services. The Iowa Central Community College Dental Hygiene Student Clinic will help prepare the patients
insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this
Dental Hygiene clinic cannot render services on the assumption that our charges will be paid by an insurance company.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said
services to said Doctor, or his assignee, at the time said services are rendered. I further agree that a waiver of any breach of any time or condition
hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be
instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
have any change in my health, I will inform the clinic at the next appointment without fail.
I am able to read and speak English.
I have received a copy of the privacy practices of the Iowa Central Dental Hygiene Clinic.
____________________________________________________
Signature of patient, parent or guardian, or guarantor of payment
Date: __________
Relationship to Patient:

Iowa Central Community College
Dental Hygiene Student Clinic
This is a teaching clinic. All treatment is provided by dental hygiene students. Dental hygiene students
are supervised by licensed dental hygiene faculty and a licensed dentist. Services performed are limited
to preventive treatment and not intended to take the place of restorative dental treatment. Our teaching
clinics strive to provide the best care for you; however there are some treatments that our students
cannot provide. You may need to see a private dental office for further treatment.
Fees will be charged for all dental hygiene services performed, however, they are greatly reduced from
those in private practices, and payment is due at time of service. You will be responsible for paying the
costs of the dental hygiene services provided.
Payment must be submitted at each appointment for the treatment received. The clinic will accept cash,
check, debit or credit card.
If you have dental insurance coverage, you will be given a form to submit to your insurance company
for reimbursement.
Please be aware that your dental insurance may not reimburse you for all your treatment costs.
Unattended children are not allowed in the reception area. Persons who are not patients are not allowed
on the clinic floor. This may be waived if there are extenuating circumstances.
Patient Eligibility
Iowa Central Community College Dental Hygiene Clinic is an educational institution and provides
preventative and oral hygiene patient treatment. In general, all persons who are able to afford the time
and the cost will be treated at the school. Furthermore, patients whose medical or emotional
management would be beyond the ability of the student in a school setting may not be accepted for
treatment.
New Patients
Appointments for new patients for consultations, radiographs, or hygiene services are usually
scheduled by the Dental Hygiene student. Appointments may be scheduled by contacting the clinic
receptionist.
Patient Assignment Procedures
All patients are screened by the student and faculty and categorized according to the complexity of
their dental hygiene needs. Student assignment may be made by the clinic instructors and is closely
linked to the need of providing appropriate clinical experience to students based on their need to
achieve and maintain clinical competency.
Last modified 08-28-09

Procedures
The following is a list of dental hygiene services and functions taught to clinical competency and
performed by dental hygiene students in the Dental Hygiene Clinic. Treatment is prescribed by
licensed dentists employed by the college to supervise clinic sessions. Licensed dental hygienists are
employed in the clinic to instruct, evaluate, and enhance the students’ clinical learning experiences.
1. Clinical infection control procedures
2. Social, medical and dental history data collection
3. Blood pressure and pulse measurements, temperature and respiration rates
4. Extra-oral and intraoral examinations (Cancer Screening)
5. Dental charting
6. Periodontal charting and assessment
7. Patient oral health education
8. Dental hygiene assessment, treatment planning, and evaluation
9. Oral radiographs – exposing, processing and interpreting
• Bitewing x-ray
• Full mouth x-rays
• Panographic x-rays
10. Calculus detection
11. Ultrasonic scaling
12. Periodontal scaling
13. Root (planing) debridement
14. Polishing
15. Application of topical fluoride
16. Application of dental sealants
17. Application of tooth desensitization
18. Application of topical anesthetic agents, including transoral delivery system
19. Local anesthesia as needed
20. Removal of interproximal overhangs
21. Application of chemotherapeutic agents including subgingival irrigation
22. Nutritional counseling
23. Alginate impressions and study models
24. Cleaning of removable prosthetic appliances
The following procedures are taught to laboratory competency*
1. Placement and removal of rubber dams
2. Maintenance of dental implants
3. Finishing and polishing amalgam restorations
4. Suture removal
5. Pulp vitality
6. Placement and removal of periodontal dressings
7. Soft tissue curettage
*Procedures taught to laboratory competence are delegable to a licensed dental hygienist in the state of Iowa by a licensed dentist. The theory and process
pertaining to these procedures are presented to students in dental hygiene courses. Students practice the procedures on student partners or manikins under
direct faculty supervision. These procedures may be prescribed and provided to a community patient when such need has been determined during the
assessment process; however, since adequate pool of patients is not always available, students are not required to achieve clinic competence prior to
graduation.
Last modified 08-28-09

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Each time you visit the Iowa Central Community College Dental Clinic, a record of your visit is made.
This record includes information about your symptoms, examinations, medications you take, your
allergies, your medical and dental histories and the plan for your care. This information we refer to as
your health or dental record and is an essential part of the dental care we provide for you. Your dental
record contains personal health information and there are state and federal laws to protect the privacy
of your health information.
In this notice we will tell you how we may use and disclose protected health information about you.
Protected health information means any health information about you that could identify you (for
example, your date of birth or social security number). In this notice, we will refer to protected health
information as your health information.
This notice will tell you about our privacy practices in accordance with the laws and will tell you
about your rights and duties in regard to your health information. Also, it will describe how you
can complain to us if you think we have violated your privacy rights.
We are required by law to:
a. maintain the privacy of your health information;
b. provide you with notice of our legal duties and privacy practices; and
c. abide by the terms of this Notice of Privacy Practices.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. All student dental hygienists, clinical staff, and supervisors involved in your care will read
and document in your dental record about your examinations, the care plan for you, the care that you received
and the results of that care. Your health information may be used and disclosed by those who are involved in
your care for the purpose of providing, coordinating, or managing services and supports. This includes
consultation with supervisors or other team members.
If you were referred to us by another provider, your Iowa Central Community College Dental Clinic provider
may send copies of your dental record to the provider who referred you to us so your provider will have updated
treatment information about your care. We may share or disclose your health information with other health care
providers so that the services you receive related to your health will be able to work together. For example, we
may refer you to professionals for services we cannot provide so as to obtain new services for you. When we do
this we need to tell them about you and your needs.
We may also use information from your dental record to call you or send you a letter or postcard to remind you
about an appointment, to follow up with diagnostic test results, to advise you of your treatment status, or to
provide you with information about treatment and care that can benefit your health.
For Payment. We may use and disclose health information about you so that we can receive payment for the
services we provide to you. Examples of such activities are billing a third party payor, such as Medicaid or your
insurance company. We may need, for example, to provide the Medicaid program with information about the
services we provide to you so that we will be paid for those services. Also, we may need to provide the
Medicaid program with information to make sure you are eligible for the medical assistance program.
Last modified 08-28-09

For Health Care Operations. There are a few other ways we may use or disclose your health information for
what are called health care operations. For example, we may use your health information to see where we can
make improvements in the services we provide. We may use the information to explore ways to more
efficiently manage our business, for licensing or accreditation activities, or for our compliance program.
Iowa Central Community College Dental Clinic is a teaching facility so it is also probable that we will use
your dental record in the process of educating and training students.
You have the right to request a restriction on the above uses and disclosures of your protected health
information for treatment, payment and health care operations; however, we are not required to agree to your
request. If we do agree, we will comply with your request unless the information is needed to provide you
emergency treatment. We may, however, also end the agreement at any time after informing you of such.
OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
Disclosures to individuals involved in your care or payment for your care: We may disclose to a
guardian/parent, personal representative, family member, or any other person identified by you, health
information that is relevant to that person’s involvement with the support s and service s you receive or
payment for that service and support. For example, if there is a health emergency, we may need to notify
one of the above identified persons of your health situation. If there is a family member or other relative
that you do not want us to disclose health information about you, please notify us via mail Renee Piper 303
Avenue M, Fort Dodge Iowa 50501
Verbal Permission: We may use or disclose your information to family members that are directly involved in
your treatment with your verbal permission.
Appointment Reminders: We may use and disclose health information to reschedule or remind you of
appointments or meetings regarding your treatment.
How We Will Contact You: If you want us to call or write to you only at your home or work or prefer
some other way to reach you, we can usually arrange that. If you want to request that we communicate
with you in a certain way or at a certain place, see “Right to Request Confidential Communications” in this
Notice. Unless you tell us otherwise, we may contact you either by telephone or by mail at either your
home or work. At either location, we may leave messages for you on the answering machine or voice mail
concerning health information.
Treatment and Service Alternatives: We may use or disclose your health information to tell you about or
suggest possible treatments or services that may be of interest to you.
Business Associates: Certain aspects and components of our services are performed through contracts with
outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be
necessary for us to provide certain of your personal health information to one or more of these outside
persons or organizations who assist us with our payment/billing activities and health care operations. In
such cases, we require these business associates to appropriately safeguard the privacy of your information.
Public Health: We may disclose health information about you for public health activities. These activities
may include disclosures
a. to a public health authority authorized by law to collect or receive such information for the purpose
of preventing or controlling disease, injury, or disability;
b. to appropriate authorities to receive reports of abuse and neglect;
c. to FDA-regulated entities for purposes of monitoring or reporting the quality, safety, or
effectiveness of FDA-regulated products; or
Last modified 08-28-09

d. to notify a person who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition.
For Law Enforcement Purposes: We may disclose health information about you to a law enforcement
official as required by law, in response to a court, grand jury or administrative order, subpoena or warrant.
We may also disclose health information to identify or locate a suspect, material witness, missing person or
fugitive or about an actual or suspected crime victim if that person agrees to the disclosure. In limited
circumstances, if we are unable to obtain that person’s agreement the information may still be disclosed.
Threats to Health or Safety: We may use or disclose protected health information about you if we believe
the disclosure or use is necessary to prevent or lessen an imminent or serious threat to the health or safety
of a person or the public. We may also release information if we believe it is necessary for law enforcement
to apprehend or identify a person who admitted participation in a violent crime or who is an escapee from a
correctional institution or from lawful custody.
Community Health Center Fort Dodge: Because Iowa Central Dental Hygiene and Community Health
Center Fort Dodge share an electronic record keeping system, your health information may be accessed by
CHCFD employees for healthcare purposes.
For Specific Government Functions: We may disclose the health information of military personnel and
veterans to government benefit programs relating to eligibility and enrollment. We may disclose your
health information to Worker’s Compensation and Disability programs, to correctional facilities if you are
an inmate, and for national security reasons.
We will not use information in your records for marketing purposes.
Other uses and disclosures from your dental record will be made only with your written authorization or
approval.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding the health information we maintain about you. To exercise any of these
rights, please submit your request in writing to us via mail, Renee Piper 303 Avenue M, Fort Dodge Iowa
50501 or via phone at (800) 362-2793 ext.2335, or tell the student who is providing services to you and the
student will provide to you a form for you to record your request.
• Right of Access to Inspect and Copy Your Dental Records. You have the right, which may be
restricted only in exceptional circumstances, to inspect and copy health information that may be used to
make decisions about your care. Your right to inspect and copy health information will be restricted
only in those situations where there is compelling evidence that access would cause serious harm to you.
We may charge a reasonable, cost-based fee for copies. We will act on your request within thirty (30)
calendar days after we receive your written request. If we deny the request, we will inform you of the
reasons for the denial in writing, how you can have the denial reviewed, and how you may complain.
• Right to Request an Amendment to Your Dental Records. If you feel that the health information we
have about you is incorrect or incomplete, you may ask us in writing to amend the information although
we are not required to agree to the amendment. We will act on your request within 60 (sixty) calendar
days after we receive your request.
• Right to an Accounting of Disclosures. You have the right to request in writing an accounting of
certain of the disclosures that we make of your health information. This accounting may be for up to six
years prior to the date on which you request the accounting but not before April 14, 2003. We may
Last modified 08-28-09

charge you a reasonable fee if you request more than one accounting in any 12-month period. We will
act on your request within sixty (60) calendar days after we receive your request.
• Right to Request Restrictions on Use or Disclosure of Your Health Information. You have the
right to request in writing a restriction or limitation on the use or disclosure of your health information
for treatment, payment, or health care operations at any time. You also have the right to request that we
restrict the use s or disclosure s we make to a family member or any other person you identify or to
public/private entities for disaster relief. For example, you could ask that we not disclose your
information to your sister or brother. We are not required to agree to any requested restriction.
• Right to Request Confidential Communication. You have the right to request that we communicate
with you about health matters in a certain way or at a certain location. For example, you may ask that
we only contact you at home or by mail. You do not have to tell us why you are choosing this way of
communicating confidential information. We may require an alternate method or address to contact
you.
• Right to a Copy of this Notice. You have the right to a paper copy of this Notice of Privacy Practices.
To obtain a paper copy of this notice, please let us know.
• The Dental Hygiene Program is in compliance with the Iowa Dental Practice Act, Occupational Safety
Hazards Act (OSHA) and Center for Disease Control and Prevention (CDC), universal precautions and
guidelines for preventing transmission of blood-borne pathogens as well as hazards control measures.
There is potential risk even utilization of the above control measures.
Iowa Central Community College reserves the right to change this Notice of Privacy Practices and its
policies and procedures for privacy practices at any time and to make the changes effective for all
protected health information created or received prior to the new effective date and then currently
maintained by Iowa Central Community College’s Dental Clinic. The revised Notice will be posted in the
College’s Dental Clinic lobby. You may also obtain a copy of the revised Notice from the Dental Clinic
office.
COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with us.
To file a complaint, contact us via mail Renee Piper 303 Avenue M, Fort Dodge Iowa 50501 or via phone at
(800) 362-2793 ext. 2335. You may complain to the Secretary of Health and Human Services at 200
Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257.
You will not be retaliated against or treated differently for filing a complaint.
If you have questions or problems:
If you need more information or have questions about the privacy practices described above, please contact
Renee Piper, 303 Avenue M, Fort Dodge Iowa 50501 or via phone at (800) 362-2793 ext. 2335.
Effective Date: August 1, 2006
Last modified 08-28-09

Consent for Use and Disclosure of Health Information
Purpose: To obtain a client’s consent to use and disclosure of the client’s protected health information to carry out
treatment, payment activities, and healthcare operations, as described more fully in Iowa Central Community
College’s Notice of Privacy Practices.
Client’s Name: ______________________________________________________________
Address: ___________________________________________________________________
Telephone: _______________________
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 health care 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 disclosures we may make of your protected health information, and of other important
matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you
to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. 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 health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by
contacting: Iowa Central Dental Hygiene Clinic, One Triton Circle, Fort Dodge, Iowa 50501, 1-800-362-2793,
extension 1327.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your
revocation submitted to the contact information listed above. Please understand that revocation of this Consent will
not affect any action we took in reliance on this Consent before we received your revocation, and that we may
decline to treat you or to continue treating you if you revoke this Consent.
I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy
Practices. I understand that by, by signing this Consent 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.
Client’s Signature: __________________________________________
Date: _____________
If the Consent is signed by a parent or personal representative on behalf of the client, complete
the following:
Personal Representative’s Name: __________________________________________________
Relationship to Client: __________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT