Medical History Form

Patient Information

Date

Patient Name

Address

City

State

Zip

Age

Birthdate

Patient SS#

Occupation

Employer

Employer Email

Employer Phone

Spouse's Name

Birthdate

SS#

Occupation

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Policyholder's Name

Birthdate

SS #

Relationship to Patient

ASSIGNMENT AND RELEASE

I,the undersigned certify that I (or my dependent) have insurance coverage with

and assign directly to Dr.

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Signature

Relationship

Date

Phone Numbers

Home Phone

Cell Phone

Work Phone

Ext

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name

Relationship

Home Phone

Cell Phone

Work Phone

Medications

List medications you are currently taking

Pharmacy Name

Phone

Allergies

Aspirin

Barbiturates (Sleeping Pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

If other, please specify

Reason for Today's Visit

Health History

Physician's Name

Date of Last Visit

If "Hepatitis" was checked, What Type?

If "Are you Pregnant?" was checked, Due Date?

If other, Please specify

Dental History

Reason for today's Visit

Former Dentist

City

State

Zip

Date of Last Dental Visit

Date of Last Dental X-Rays

If Other, Please specify

How often do you floss?

How often do you brush?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Legal Guardian's Signature

Date

Doctor's Signature

Date

Your information will be encrypted.