Medical History Update

Patient Name

Date of Birth

Address

City

State

Zip Code

Phone #

Email address

Work

If yes, please provide the new insurance card to front desk!

MEDICAL/DENTAL HISTORY - Have you ever had any of the following? (Check the boxes that apply)

If yes, please explain

If yes, Please explain

When was your last dental cleaning?

Women

Please list medications/doses you are currently taking:

Add Medication

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form:

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

Your information will be encrypted.