Health History

Patient Name

Dental History

Reason for today's visit:

Date of last dental care:

Date of last dental x-ray:

Former Dentist

Their Address

How often do you brush?

How often do you floss?

Medical History

Physician's Name

Date of last visit

Have you ever taken any of the group of drugs collectively referred to as "ten-phen"? These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes No

Have you ever had any serious illnesses or operations?

Yes No

If "Yes", please explain:

Have you ever had a blood transfusion?

Yes No

If "Yes", please give an approximate date:

(Women) Are you:

Pregnant

Nursing

Taking birth control pills

Please list all medications that you are currently taking, and the correlating diagnosis:

Add Medication

Please list any allergies that you have:

Add Allergy

Acknowledgement of Receipt of Notice of Privacy Practices.

I acknowledge that I have received a Notice of Privacy Practices from Kewaskum Family Dentistry

Medical Information Authorization & Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform the doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance at the company named above, and assign directly all insurance benefits, if any, otherwise payable to me for services rendered to the doctor listed below.

Doctor's Name

I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

Patient Signature

Patient Name

Today's Date

Parent, Legal Guardian or Representative

Relationship to Patient

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Payment is due in full at the time of treatment unless prior arrangements have been approved.

Your information will be encrypted.