Health History Update
Patient Name:
Date:
*
-
Month
-
Day
Year
Date
Are there any changes to patient’s contact information?
Yes
No
Contact Information
If yes, indicate changes below.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Other than the person signing below, are there other individuals authorized to make financial/treatment decisions for the patient?
Yes
No
If yes, please list name and relationship:
Dental Insurance Information
Please provide us with a copy of your current dental insurance card.
Insurance Company:
ID/SSN:
Name of Policy Holder:
Date of Birth:
-
Month
-
Day
Year
Date
Policy Holder’s employer:
Health History
Any health issues we need to be aware of?
Yes
No
If yes, please explain:
Is the patient taking any medications?
Yes
No
If yes, please list:
List any allergies or drug sensitivities:
Females only: Age of first menses:
Dental History
Patient’s Dentist:
Month/year of last cleaning:
Month/year of last dental x-rays:
Are there any new dental problems or injuries to mouth or jaws we need to be aware of?
Yes
No
If yes, please explain:
Signature
Please sign to acknowledge the above information is correct.
Signature of Parent or Guardian:
Clear
Date Submitted:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: