Patient Information Update

Patient Information Update

Please completely fill out form.
Patient's Legal Name*
Patient's Preferred Pronouns*
Patient Preferred Name*
Patient Birth Date*

MonthDayYear
Date
Patient Age*
Sex*

MaleFemale
School/Occupation
General Dentist
Referred By
Patient Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Home Phone

Area CodePhone Number
Patient Cell Phone

Area CodePhone Number
Patient Work Phone

Area CodePhone Number
Siblings/Children's Names & Ages
Patient/Parent 1/Partner
Name
Marital Status

MarriedWidowedDivorcedSingle
Is address same as above?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Social Security Number
Birthdate

MonthDayYear
Date
Email*
example@example.com
Employer
Occupation
No. of years employed
Parent 2/Spouse/Partner
Name
Marital Status

MarriedWidowedDivorcedSingle
Is address same as above?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Social Security Number
Birthdate

MonthDayYear
Date
Email
example@example.com
Employer
Occupation
No. of years employed
Person financially responsible for this account?*

SelfParent 1Parent 2
Parent's Marital Status

MarriedWidowedDivorcedSingle
Dental Insurance Information
Do you have dental insurance?*

YesNo
Primary Insurance Company
Insurance Phone

Area CodePhone Number
Insurance Company Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee Name
Employer
Employee Birthdate

MonthDayYear
Date
SSN
Subscriber I.D No.
Do you have secondary insurance?

YesNo
Insurance Company
Insurance Phone

Area CodePhone Number
Employee Name
Employer
Employee Birthdate

MonthDayYear
Date
SSN
Medical History Update
Have there been any significant changes in your health history?*

YesNo
If yes, please explain:
Are you taking any medications at this time?*

YesNo
If yes, please explain:
Do you have any allergies to any medication?*

YesNo
If yes, please list:
Latex allergy?*

YesNo
Any other changes we should be aware of?*

YesNo
If yes, please explain:
HIPAA/Medical Information Release
Release of Information*

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.I DO NOT authorize the release of information including the diagnosis, records; examination rendered to me and claims information.
This information may be released to:

MotherFatherSpouseChild(ren)Information is not to be released to anyone
*This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call:

My homeMy workMy cell
If unable to reach me:

you may leave a detailed messageplease leave a message asking me to return your call
The best time to reach me is:
Day:
Time:
Signature

The above information is correct to the best of my knowledge.
Signature*

Clear
Date Submitted*

MonthDayYear
Date
Person filling out this form:
Relationship to patient:
Should be Empty:

Patient Information Update

Patient/Parent 1/Partner

Parent 2/Spouse/Partner

Dental Insurance Information

Medical History Update

HIPAA/Medical Information Release

Messages

Signature