Medical Update Form

Patient Name

Patient Address

Patient Insurance

Insurance Name

Subscriber Name

Subscriber ID

Group Number

Insurance Phone #

Patient Medical History

Name of Physician

Phone #

1. Are you in good health?

Yes No

2. Has there been any change in your general health in the last year?

Yes No

If yes, please explain:

3. Have you been recently hospitalized, had a major operation or serious illness?

Yes No

If yes, please explain.

4. Date of your last visit to your doctor?

Reason for last visit

5. Are you now under a doctor’s care for a particular problem at this time?

Yes No

If yes, for what condition(s)?

6. For women: Are you pregnant or do you think you could be pregnant?

Yes No

Other Medications if applicable:

8. Are you allergic to or have you had any reactions to the following?

Penicillin

Aspirin

Codeine

Sulfonamides

Barbiturates

Iodine

Latex

Other (Please List):

Other Allergies if applicable:

SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give permission to the dentist to obtain from my physician any additional information regarding my medical history needed to provide me with the best dental treatment possible.

Signature

Date

I allow the office of Dr. Tom Long to confirm my appointments by email and/or text message.

ACKNOWLEDGEMENT OF RECIEPT OF HIPPA PRIVACY PRACTICES

NOTE: You may refuse to sign this acknowledgement.

I have reviewed a copy of this office’s HIPPA Notice of Privacy Practices.

Please list anyone you wish to share information with.

Signature

Date

Your information will be encrypted.