Medical History Form

Full Name

Birthdate

Today's Date

Address

City

State

Zip

Phone No.

Soc. Sec. No.

Drivers License No.

Occupation

Employer

Phone No. of Employer

Address of Employer

City

State

Zip

Spouse

Spouse Soc. Sec.

Spouse Employer

Employer Phone No.

Address

City

State

Zip

If patient is under 18, who is the responsible party

Phone No.

Address of responsible party

City

State

Zip

How did you hear about us?

INSURANCE INFORMATION: must be completed in detail and your card provided OR WE CANNOT FILE YOUR INSURANCE. YOU WILL BE RESPONSIBLE FOR CASH PAYMENT!

Name of Insurance Carrier

Group No.

Relationship to Employee

Soc. Sec.(if different)

Employee's Birthdate (if different)

Employer (if different)

Employer Address (if different)

City

State

Zip

Is the patient covered by a second plan?

Carrier

Group No.

Name of Group Plan

Employer

Employer Address

MEDICAL HISTORY

Physician

Specialty

Phone No.

Address

Date of last exam

Add Additional Physician

Height

Weight

Age

Current Medical Problem?

If yes, How much?

If yes, Please specify

DENTAL HISTORY

Previous Dentist

Specialty

Address

Phone No.

Last Dental Visit

Last full mouth radiographs

What is your current dental problem?

Have you had any of the following?

Braces

Root Canal

Gum Disease / Surgery

Tooth Extraction

Jaw Joint Treatment

When was your last dental cleaning?

Did you get cleanings routinely?

Have you had any of these problems? (if so, describe)

If yes, Please describe

Why?

How?

How long have you had them?

What do you expect of your new dentures?

To the best of my knowledge, all of the preceding answers are correct. I authorize dental treatment to be rendered by Dr. Harris and his staff, and assume financial responsibility

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

MEDICAL UPDATES

Initial

Date

Initial

Date

Initial

Date

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