Returning Patient Update Form

First Name, Last Name

Date

Contact Info Update

Email address

Address

City

State

Zip Code

Phone No.

Emergency Contact Name

Emergency Contact Phone No.

Your most recent insurance information

Policy Holder Information

Relationship to Patient

First Name

Middle Name

Last Name

Date of Birth

Address

City

State

Zip

Insurance Company Name

Insurance Company Phone No.

Group Number

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Lucky Smiles Dentistry 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 payments of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Name

Relationship

CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

Medical History Update

Have you had any changes in your medical condition (Hip/Shoulder/Knee replacements, Heart condition, autoimmune condition, Thyroid, etc) in the last 6-12 months? If so, please explain

Physician's Name

Physician's Phone number

Date of Last visit

Please list any drugs, medications, over the counter meds, or vitamins you are currently taking:

Are you taking bisphosphonate?

Yes No

If other, Please specify

If other, please specify

If Female, Are you pregnant

Yes No

Your due date?

Dental

What specific questions or concerns you would like us to address today?

None

Pain

Veneers/Crowns

Whitening

Straighten teeth

Sensitivity

Replace missing teeth

Implants

Other

Do you require antibiotics before dental treatment?

Yes No

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately. I understand that providing false or incorrect information can be dangerous to my health.

I certify that I have read the office’s Notice of Privacy Practices

Authorization for release of information to family members if needed. Please provide their Names, Relationships, and Phone numbers

Add additional names

I have read and agree to the 24-hour cancellation notice and understand that if I need to cancel or reschedule my appointment I need to provide at least 24 hours' notice. Failure to do so will result in a $50 fee.

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

Your information will be encrypted.