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Desoto County Health Department Dental Clinic Triage Form INFORMATION YES ARE YOU A NEW PATIENT Last name NO First Middle Street address P. O. box Home Phone Number State City Emergency Contact Not Living With You Name Birthdate Social Security Number ZIP Code Phone Address OTHER INFORMATION STATUS Single Married INSURANCE INFORMATION Separated NONE Divorced GROUP Widowed ID HOUSEHOLD STATUS/EMPLOYMENT INFORMATION Name of Employer OTHER INCOME Child Support Retirement SSI AFDC/Food Stamps VA Benefits Unemployment Benefits Worker s Compensation Contributions from friends/relatives Student Loans None REASON FOR VISIT PLEASE LIST YOUR PRESENT HEALTH CONCERNS PROBLEMS OR SYMPTOMS AUTHORIZATION FOR TREATMENT I HEREBY CERTIFY THAT ALL INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE* I HEREBY APPLY FOR AND GRANT PERMISSION TO RECEIVE ALL NECESSARY MEDICAL TREATMENT AVAILABLE THROUGH THE DESOTO COUNTY HEALTH DEPARTMENT FOR MYSELF AND/OR MY FAMILY. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. Client/Parent/Guardian/Responsible Party DATE YOU ARE REQUIRED TO COMPLETE THE FOLLOWING FOR A SLIDING SCALE DISCOUNT BASED ON TOTAL FAMILY INCOME* HEAD OF HOUSEHOLD INFORMATION Relationship Employed by Total Income Weekly Bi- weekly Monthly WAGE EARNER 2 LIST ALL HOUSEHOLD MEMBERS NAME SELF DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER. O. box Home Phone Number State City Emergency Contact Not Living With You Name Birthdate Social Security Number ZIP Code Phone Address OTHER INFORMATION STATUS Single Married INSURANCE INFORMATION Separated NONE Divorced GROUP Widowed ID HOUSEHOLD STATUS/EMPLOYMENT INFORMATION Name of Employer OTHER INCOME Child Support Retirement SSI AFDC/Food Stamps VA Benefits Unemployment Benefits Worker s Compensation Contributions from friends/relatives Student Loans None REASON FOR VISIT PLEASE LIST YOUR PRESENT HEALTH CONCERNS PROBLEMS OR SYMPTOMS AUTHORIZATION FOR TREATMENT I HEREBY CERTIFY THAT ALL INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE* I HEREBY APPLY FOR AND GRANT PERMISSION TO RECEIVE ALL NECESSARY MEDICAL TREATMENT AVAILABLE THROUGH THE DESOTO COUNTY HEALTH DEPARTMENT FOR MYSELF AND/OR MY FAMILY. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. Client/Parent/Guardian/Responsible Party DATE YOU ARE REQUIRED TO COMPLETE THE FOLLOWING FOR A SLIDING SCALE DISCOUNT BASED ON TOTAL FAMILY INCOME* HEAD OF HOUSEHOLD INFORMATION Relationship Employed by Total Income Weekly Bi- weekly Monthly WAGE EARNER 2 LIST ALL HOUSEHOLD MEMBERS NAME SELF DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER.

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