Patient Medical History & Update Form

Name

Date

Name

Address

City

State

Zip

Home Phone

Email address

Work Phone

Cell Phone

What is the best way to reach you in case of an emergency?

Primary Dental Insurance Company

Secondary Insurance Company

Primary Care Physician Name

Primary Care Physician Phone

Pharmacy Name

Pharmacy Phone

Emergency Contact Name

Emergency Contact Phone

If Other, Please specify

Do you smoke or use tobacco?

Yes No

Women Only

Are you pregnant?

Yes No

If yes, how many weeks?

Are you taking Birth Control?

Yes No

Are you nursing?

Yes No

Please List All Current Medications & Dosages

Have you had any serious Illnesses or operations?

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.

Signature

Date

OFFICE USE ONLY

Premed

Script

Your information will be encrypted.