Medical Update Form

Please correct the errors described below.

If yes, please list name and dosage:

Add medication/drugs/pills

If yes, please list:

Add medication/substance

Indicate which of the following you have had, or have at present. Circle "yes" or "no" to each of them.

If yes, please list:

Add disease condition or problem


I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency who may release such information to you. I will notify the doctor of any change in my health or medication.

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.

Your information will be encrypted.