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English to Dinka English to Luganda English to Shona English to Bemba Bemba to English English to Afrikaans English to Kikuyu Afrikaans to English Dinka to English Lingala to English English to Lingala Luganda to English Kirundi to English English to Kirundi Southern Sotho / Sesotho to English English to Southern Sotho / Sesotho Shona to English Tigrinya to English English to Tigrinya Xhosa to English English to Xhosa Zulu to English English to Zulu English to Ewe Ewe to English English to Twi Twi to English Dholuo (Lwo) to English Swahili to English Amharic to English Somali to English Kinyarwanda to English Kikuyu to English English to Afar English to Akan Akan to English English to Arabic Arabic to English Basa to English English to Basa Nyanja to English English to Nyanja English to Dari Dari to English English to Fanti (Fante) Fanti (Fante) to English English to Persian (Farsi) Persian (Farsi) to English English to Fulah (Fulani) Fulah (Fulani) to English English to Hausa Hausa to English English to Hebrew Hebrew to English English to Igbo Igbo to English Kamba to English English to Kamba English to Karen Karen to English English to Acoli Acoli to English English to Krio Krio to English English to Masai Masai to English English to Maay Maay Maay Maay to English English to Malagasy Malagasy to English English to Mandingo / Maninka Mandingo / Maninka to English English to Nkore / Runyankole Nkore / Runyankole to English English to SothoNorthern SothoNorthern to English English to Oromo Oromo to English English to Tonga (Nya) Tonga (Nya) to English English to Tonga(TongaIslands) Tonga(TongaIslands) to English English to Tsonga Tsonga to English English to Tswana Tswana to English English to Urdu Urdu to English English to Venda Venda to English English to Wolof Wolof to English English to Yoruba Yoruba to English Adangme to English English to Adangme Albanian to English English to Albanian Afar to English Armenian to English Aramaic to English English to Aramaic English to Assamese Assamese to English Azerbaijani to English English to Azerbaijani English to Basque Basque to English English to Bambara / Bamanakan Bambara / Bamanakan to English English to Bengali Bengali to English Bosnian to English English to Bosnian English to Bini/Edo Bini/Edo to English English to Bulgarian Bulgarian to English English to Burmese Burmese to English Catalan to English English to Catalan Chinese to English English to Chinese English to Chamorro Chamorro to English Chin to English English to Chin English to Creoles & Pidgins (Other) Creoles & Pidgins (English-based Other) to English English to Creoles & Pidgins (Portuguese-based Other) English to Croatian Croatian to English English to Dagbani Dagbani to English English to Czech English to Danish Danish to English English to Chuukese Chuukese to English English to Dzongkha
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Rates
English to Amharic - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Somali - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Swahili - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Kinyarwanda - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Dholuo (Lwo) - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour
English to Dinka - Rates: 0.15 - 0.15 USD per word / 40 - 40 USD per hour English to Luganda - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Shona - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Bemba - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Bemba to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Afrikaans - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Kikuyu - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Afrikaans to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Dinka to English - Rates: 0.15 - 0.15 USD per word / 40 - 40 USD per hour Lingala to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Lingala - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Luganda to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Kirundi to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Kirundi - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Southern Sotho / Sesotho to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Southern Sotho / Sesotho - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Shona to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Tigrinya to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Tigrinya - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Xhosa to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Xhosa - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Zulu to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Zulu - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Ewe - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Ewe to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Twi - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Twi to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Dholuo (Lwo) to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Swahili to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Amharic to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Somali to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Kinyarwanda to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Kikuyu to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Afar - Rates: 0.10 - 0.15 USD per word / 30 - 30 USD per hour English to Akan - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Akan to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Arabic - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Arabic to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Basa to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Basa - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Nyanja to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Nyanja - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Dari - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Dari to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Fanti (Fante) - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Fanti (Fante) to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Persian (Farsi) - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Persian (Farsi) to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Fulah (Fulani) - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Fulah (Fulani) to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Hausa - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Hausa to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Hebrew - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Hebrew to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Igbo - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Igbo to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Kamba to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Kamba - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Karen - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Karen to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Acoli - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Acoli to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Krio - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Krio to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Masai - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Masai to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Maay Maay - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Maay Maay to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Malagasy - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Malagasy to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Mandingo / Maninka - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Mandingo / Maninka to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Nkore / Runyankole - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Nkore / Runyankole to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to SothoNorthern - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour SothoNorthern to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Oromo - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Oromo to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Tonga (Nya) - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Tonga (Nya) to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Tonga(TongaIslands) - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Tonga(TongaIslands) to English - Rates: 0.20 - 0.20 USD per word / 80 - 80 USD per hour / 10.00 - 10.00 USD per audio/video minute English to Tsonga - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Tsonga to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Tswana - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Tswana to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Urdu - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Urdu to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Venda - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Venda to English - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour English to Wolof - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour Wolof to English - Rates: 0.15 - 0.15 USD per word / 30 - 30 USD per hour English to Yoruba - Rates: 0.10 - 0.10 USD per word / 20 - 20 USD per hour Yoruba to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour Adangme to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour English to Adangme - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour Albanian to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour English to Albanian - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour Afar to English - Rates: 0.20 - 0.20 USD per word / 40 - 80 USD per hour / 10.00 - 10.00 USD per audio/video minute Armenian to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Aramaic to English - Rates: 0.20 - 0.20 USD per word / 40 - 80 USD per hour / 10.00 - 10.00 USD per audio/video minute English to Aramaic - Rates: 0.20 - 0.20 USD per word / 40 - 80 USD per hour / 10.00 - 10.00 USD per audio/video minute English to Assamese - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Assamese to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Azerbaijani to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Azerbaijani - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Basque - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Basque to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Bambara / Bamanakan - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Bambara / Bamanakan to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Bengali - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Bengali to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Bosnian to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Bosnian - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Bini/Edo - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Bini/Edo to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Bulgarian - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Bulgarian to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Burmese - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Burmese to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Catalan to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Catalan - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Chinese to English - Rates: 0.10 - 0.10 USD per character / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Chinese - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Chamorro - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute Chamorro to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour Chin to English - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Chin - Rates: 0.15 - 0.15 USD per word / 20 - 40 USD per hour / 8.00 - 8.00 USD per audio/video minute English to Creoles & Pidgins (Other) - Rates: 0.20 - 0.20 USD per word / 20 - 40 USD per hour / 10.00 - 10.00 USD per audio/video minute Creoles & Pidgins (English-based Other) to English - Rates: 0.20 - 0.20 USD per word / 20 - 40 USD per hour / 10.00 - 10.00 USD per audio/video minute English to Creoles & Pidgins (Portuguese-based Other) - Rates: 0.20 - 0.20 USD per word / 20 - 40 USD per hour / 10.00 - 10.00 USD per audio/video minute English to Croatian - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Croatian to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour English to Dagbani - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute Dagbani to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour English to Czech - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour / 6.00 - 6.00 USD per audio/video minute English to Danish - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour Danish to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour English to Chuukese - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour Chuukese to English - Rates: 0.10 - 0.10 USD per word / 20 - 40 USD per hour English to Dzongkha - Rates: 0.15 - 0.15 USD per word / 40 - 60 USD per hour / 8.00 - 8.00 USD per audio/video minute
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TO THE PATIENT, PARENT, OR GUARDIAN — PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
Purpose of Consent: By signing this form, youwill consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Joint 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 importantmatters 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. You are entitled to a copy of this formif you would like one... just ask.
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 Joint 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 ourJoint Notice of Privacy Practices, including any revisions of ourNotice, at any time by contacting:
Kool Smiles P.C.
HIPAA ComplianceOffice
1090NorthchaseParkwaySE
Suite 150 & 290
Marietta,GA30067
(770)916-9000
Right to Revoke: Youwill have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that wemay decline to treat you or to continue treating you if you revoke this Consent.
SIGNATURE
I, _________________________________________, have had full opportunity to read and consider the contents of this Consent form and KoolSmiles, P.C.Joint Notice of Privacy Practices. I understand that by signing thisConsent form, I am giving my consent to KoolSmiles, P.C. use and disclosure of the patient’s protected health information to carry out treatment, payment activities, healthcare operations and other uses described in theKoolSmiles P.C.Joint Notice of Privacy Practices thatwas provided to me.
Signature:
Date:
Relationship to Patient:
Translation - Swahili IDHINI YA KUTUMIA NA KUFICHUA TAARIFA YA AFYA
Jina:
Jina La Mgonjwa:
Anwani:
Nambari ya Simu:
Nambari Ya Siri:
KWA MGONJWA, MZAZI, AU MCHUNGAJI – TAFADHALI SOMA MATAMKO YAFUATAYO KWA MAKINI
Madhumuni ya Idhini: Kwa kutia saini fomu hii, unakubali matumizi yetu na kutoa taarifa zako za afya kwa kutekeleza matibabu, shughuli za malipo, na shughuli za huduma ya afya.
Taarifa ya Utibabi wa Faragha: Una haki ya kusoma Ilani yetu ya Pamoja ya Utibabi wa Faragha kabla ya kuamua kitai sahihi Idhini hii. Ilani yetu hutoa maelezo ya matibabu yetu, shughuli za malipo, na shughuli za huduma ya afya, ya matumizi na utoaji wa taarifa zako za afya tunaweza kufanya, na mambo mengine muhimu kuhusu taarifa zako za afya.
Nakala ya Ilani yetu hii inaambatana na Idhini hii. Tunakuomba uisome kwa makini na kabisa kabla ya kutia saini yako kwenye Idhini hii. Una haki ya kuwa na nakala ya fomu hii kama ungependa moja... uliza tu.
Tuna haki ya kubadilisha utibabi wa faragha zetu kama ilivyoelezwa katika Ilani yetu ya Utibabi wa Faragha. Kama tutabadilisha utibabi wa faragha zetu, tutatoa upya Ilani ya utibabi wa faragha, ambayo itakuwa na mabadiliko. Mabadiliko hayo yanaweza kutumika kwa taarifa yako yeyote ya afya ambayo tutakuwa nayo.
Unaweza kupata nakala ya Ilani yetu ya utibabi wa Faragha, ikiwa ni pamoja na marekebisho ya Ilani yetu, wakati wowote kwa kuwasiliana na:
HIPAA Compliance Office
1090NorthchaseParkwaySE
Suite 150 & 290
Marietta,GA30067
(770)916-9000
Haki ya Kupinga: Uko na haki ya kupinga hii Idhini wakati wowote kwa kutuma taarifa ya maandishi ya ubatilishaji wako kwa alietajwa hapo juu. Tafadhali elewa kwamba kuondolewa kwa Idhini hii hakutaathiri kitendo chochote tulichokifanya katika utegemeziwa Idhini hii kabla ya sisi kupokea barua ya kuondolewa kwako, na kwamba tunaweza kataa kukutibu wewe au kuendelea kukutibu wewe kama utaipinga hii Idhini.
SAHIHI
Mimi, _________________________________________, nimepata na nafasi kamili yakusoma na kuzingatia yaliyomo kwenye Idhini hii na KoolSmiles PC, Ilani ya Pamoja ya utibabi wa Faragha.
Ninaelewa kwamba kwa kutia sahihi kwenye fomu hii ya Idhini, mimi ninawapatia ruhusa yangu KoolSmiles, PC watumie na wafichue taararifa ya mgonjwa kwa shughuli za matibabu, shighuli
za malipo, shughuli za afya na matumizi mengine ilivyoelezwa katika Ilani ya KoolSmiles PCJoint ya utibabi wa Faragha niliyopatiwa mimi.
Sahihi:
Tarehe:
Uhusiani na Mgonjwa:
English to Swahili: New Patient's Information Form for Wrld Health Organization General field: Medical Detailed field: Marketing
Source text - English NPI-E Rev.04-2009
New Patient Health Information
Patient's Full Name:
Age:
Date of Birth:
Prefers to be called:
Sex:
Weight:
NO YES
Please Explain
Does patient have any health problems?
Is patient under the care of a physician now?
Has patient ever been hospitalized?
Does patient bleed excessively when cut or bruise easily?
Has patient had emotional or mental problems?
Has patient ever had any drug reactions?
Has patient ever had a local anesthetic?
Has patient had any unfavorable dental experiences?
Have patient had any injuries to the mouth or teeth?
Does patient have a toothache today or in the past month?
Is patient allergic to any medications?
Is patient allergic to any foods or drink (i.e. milk, bananas)?
Does patient have environmental allergies?
Is patient allergic to any materials commonly used in a dental office (i.e. latex gloves, anesthetic, etc.)? Explain.
Does patient have any of the following habits? (Thumb/finger sucking, tongue thrust, mouth breathing, snoring,
belching/burping) (Please circle.)
Please list prescription medication(s) being taken by the patient:
Name and phone # of patient’s pediatrician or physician:
Name and phone # of patient’s specialty medical care provider:
Has patient ever had any history or difficulty with the following? If so, please mark an "X" in the spaces provided.
( ) Cancer ( ) HIV ( ) Anemia ( ) Mononucleosis ( ) Cystic Fibrosis
( ) Liver ( ) Asthma ( ) Hepatitis ( ) Cerebral Palsy
( ) Lung ( ) Fainting ( ) Seizures ( ) Spinal Bifida ( ) Nervous Disorder
( ) Kidney ( ) Diabetes ( ) Convulsions ( ) Speech Problems ( ) Skin Condition
( ) Bladder ( ) Mumps ( ) Tuberculosis ( ) Pregnancy ( ) Developmental Delay
( ) Hearing ( ) Measles ( ) Malignancy ( ) Cleft Lip or Palate ( ) Hydrocephaly/Shunts
( ) Smoking ( ) Rubella ( ) Hemophilia ( ) Rheumatic Fever ( ) High Blood Pressure
( ) TMJ ( ) Autism ( ) Heart Surgery ( ) Thyroid ( ) Heart Disease/Congenital Defect
Please explain:
Reason for today's visit:
Please identify any dental or medical problems of special concern, or provide any other information which you think might be important in the patient’s care:
CERTIFICATION AND CONSENT FOR TREATMENT
I certify that I am the patient or parent/legal guardian of the patient listed above and the information provided in this form
is true and correct to the best of my knowledge. I also give my consent for my child or myself to receive a complete oral and dental examination (including any necessary x-rays) and dental cleaning. After consultation, I consent to all forms of treatment, medication, and therapy indicated for the dental care of the above named patient. I also understand that I am personally responsible for any patient portions left on my account. This agreement is made with Kool Smiles PC.
Signature: _____________________ Relationship to Patient (if patient is minor): ___________ Date: ________
Dentist Signature: Date:
Translation - Swahili Habari za Afya za Mgonjwa Mpya
Juna Kamili La Mgonjwa:
Umri:
Siku ya Kuzaliwa:
Anapendelea Kuitwa: Jinsia:
Uzani:
NDIO LA
Tafadhali Eleza
Je, mgonjwa ako na matatizo yoyote ya afya ?
Je, mgonjwa ako chini ya uangalizi/matibabu wa daktari kwa sasa?
Je, mgonjwa amewahi kulazwa hospitalini?
Je, mgonjwa hutokwa na damu kupita kiasi wakati anapo katwa au mchubuko?
Je, mgonjwa amewahi kuwa na matatizo ya kihisia au kiakili?
Je, mgonjwa amewahi kuwa na athari yoyote ya madawa?
Je, mgonjwa amewahi kuwa na dawa ya kugandisha misuli ya kienyeji?
Je, mgonjwa amewahi kuwa na uzoefu mbaya wowote wa meno?
Mgonjwa amewahi kuwa na majeraha yoyote kwa kinywa au meno?
Je, mgonjwa ako na maumivu ya meno leo au katika mwezi uliopita?
Je, mgonjwa ako na mzio wa dawa yoyote?
Je, mgonjwa ako na mzio wa vyakula au vinywaji (yaani maziwa, ndizi)?
Je, mgonjwa ako na mzio wa mazingira?
Je, mgonjwa ako na mzio wa nyenzo yoyote ya kawaida inayotumika katika cliniki ta meno (yaani glavu za mpira, dawa ya kugandisha misuli, na kadhalika)? Eleza.
Je, mgonjwa ako na moja ya tabia zifuatazo au mazoea yafuatayo? (Kunyonya kidole, kutia ulimi, kupumua na mdomo, mkoromo, mbweu/viungulia) (Tafadhali piga duara)
Tafadhali arodhesha dawa au madawa anazotumia mgonjwa:
Jina na nambari za simu za daktari wa mgonjwa:
Jina na nambari za simu za mtoa huduma maalum za afya wa mgonjwa:
Je, mgonjwa amewahi kuwa na historia yoyote au matatizo yafuatayo? Kama ni hivyo, tafadhali eka alama ya "X" katika nafasi iliyotolewa.
( )Saratani ( )Ukimwi ( )Safura ( )Mononucleosis
( ) Uvimbe adilifu ( )Ini ( )Umu ( )Uvimbe wa Ini ( )Kupooza ubongo ( )Pafu ( )Kuzimia ( )Kipindupindu ( )Matatizo ya Mgongo ( )Matatizo ya neva( )Figo
( )Kisukari ( )Degedege ( )Shida Ya Kuongea ( )Ujongwa wa Ngozi ( )Kibofu cha Mkojo
( )Machumbwichumbwi ( )Kifua Kikuu ( )Kuwa Mjamzito ( )Kuchelewa Kukuwa ( )Kusikia ( )Churua ( )Donda ndugu ( )Mdomo Ulioshikana
( )Maji kwenye Ubongo ( )Uvutaji Sigara ( )Rubela ( )Hemofilia ( )Homa ya baridi yabisi ( )Shinikizo la Damu
( )Uvimbe Mdomoni ( )Matatizo ya Ubongo ( )Oparesheni ya Moyo ( )Tezi ( )Ugonjwa wa Moyo/ Matatizo ya Kuzaliwa
Tafadhali eleza:
Sababu ya ziara ya leo:
Tafadhali eleza matatizo yoyote ya meno au matibabu ya shata, au toa maelezo mengine ambayo unadhani yanaweza kuwa muhimu katika huduma atayopewa mgonjwa:
UTHIBITISHO NA IDHINI YA MATIBABU
Mimi nathibitisha kuwa mimi ndimi mgonjwa au mzazi / mlezi wa mgonjwa aliyetajwa hapo juu na taarifa iliotolewa katika fomu hii ni ya kweli na sawa kwa ufahamu wangu. Mimi pia natoa idhini yangu kwa ajili ya mtoto wangu au mimi mwenyewe kupokea huduma na ukaguzi kamili wa kinywa na meno (ikiwa ni pamoja na picha ya eksirei itakayohitajika ) na kusafisha meno. Baada ya kushauriana, mimi nakubali aina zote za matibabu, dawa, na matibabu yaliyopendekezwa kwa ajili ya huduma za meno za mgonjwa aliyetajwa hapo juu. Mimi pia nafahamu ya kuwa mimi binafsi nawajibika kwa sehemu zozote za mgonjwa zinazoachwa mikononi mwangu. Mkataba huu umetengenezwa na Kool PC Smiles.
Sihihi: _____________________ Uhusiano na Mgonjwa (kama mgonjwa ni mtoto): Tarehe:
Sahihi ya Daktari wa Meno: Tarehe:
English to Swahili: Tax Return Forms General field: Bus/Financial Detailed field: Law: Taxation & Customs
Source text - English Do you need to complete a tax return?
Due to competing demands, Diversitat are unable to offer tax help this year.
Any person who has worked in Australia between July 1st 2010 and June 30th 2011 must lodge a tax return with the Australian Tax Office. You will receive a Group Certificate from your employer that you have worked for and need to keep this until you do a tax return.
Diversitat has found a company called SJ Canny that will do tax returns from $75.00. The tax returns will be done by professional taxation agents who will make sure that your tax return is done properly. A tax agent from SJ Canny will be at the Northern Community Hub one day a week to help you with your tax return if we have enough people that are interested in using this service.
Please let your caseworker know if you are interested in having your tax return done this way so that we can arrange a day for the tax agent to come to the Northern Community Hub.
Keep in mind that you can claim the $75.00 fee as a refund on next year’s tax return.
If you do not want to use this service you can find an alternative taxation agent or, under certain circumstances, help is available from the ATO Tax Help Program. This program is only for wage and salary earners or those who have only received Centerlink payments. People who have an ABN cannot use this service.
The Tax Help Program is operated by volunteers and they will only see you by appointment. If you are eligible and would like to make an appointment please call one of the following numbers - please choose the one nearest to where you live.
• Corio 5275 4597
• Hamlyn Heights 5277 9027
• Lara 5282 2725
• Belmont 5243 8388
• Waurn Ponds 5243 2400
Translation - Swahili Je, unahitaji kukamilisha fomu za ushuru?
Kutokana na kuongezeka kwa kazi/mahitaji, Diversitat hawawezi kutoa usaidizi wa ushuru mwaka huu.
Mtu yeyote ambaye amefanya kazi Australia kati ya Julai 1, 2010 na Juni 30, 2011 lazima akamilishe fomu za ushuru na Ofisi ya Ushuru ya Australia. Utapokea Cheti cha Kikundi kutoka kwa mwajiri wako ambaye umemfanyia kazi na unapaswa kukiweka cheti hicho mpaka utakapo jaza fomu za ushuru.
Diversitat imepata kampuni inayoitwa SJ Canny ambayo itafanya/itajaza fomu za ushuru kwanzia dola ($) 75.00. Fomu za ushuru zitajazwa na mawakala wa kitaalamu wa utozaji kodi ambao watahakikisha kwamba fumo zako za ushuru zimejazwa vizuri. Wakala wa ushuru kutoka SJ Canny atakuwa katika Kituo cha Jamii ya Kaskazini siku moja kwa wiki ili kukusaidia wewe kujaza fomu yako ya ushuru kama tutakuwa na watu wa kutosha ambao watakuwa na nia ya kutumia huduma hii.
Tafadhali mweleze mfanyikazi wa kesi yako ili ajue kama una nia ya kujaziwa fomu za ushuru kwa njia hii ili tuweze kupanga siku ambayo wakala wa ushuru atakuja Kituo cha Jumuiya ya Kaskazini.
Kumbuka kwamba unaweza kudai ada ya dola ($) 75.00 kama marejesho ya ushuru ya mwaka ujao.
Kama hutaki kutumia huduma hii unaweza kutafuta wakala wa utozaji kodi mwingine au, kutokana na hali fulani, usaidizi unapatikana kutoka Programu ya Usaidizi wa Ushuru ya ATO. Mpango huu ni kwa ajili ya watu wa mapato ya ujira na mshahara au wale waliopokea malipo ya Centerlink peke yake. Watu ambao wana ABN hawawezi kutumia huduma hii.
Programu ya Usaidizi wa Ushuru inaendeshwa na wafanyakazi wa kujitolea na wao watakuona tu kwa miadi. Ikiwa unastahiki na ungependa kufanya miadi tafadhali piga simu kwa moja ya nambari zifuatazo - Tafadhali chagua moja ambayo iko karibu na unapoishi.
• Corio 5275 4597
• Hamlyn Heights 5277 9027
• Lara 5282 2725
• Belmont 5243 8388
• Waurn Ponds 5243 2400
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