Patient Medical History Form

About You



 





 







 







 



 



 




 



 


 
Spouse Information



 






 

Relative or Friend not living with you

 



 



 
Insurance Information
Primary Insurance

Yes No

 



 



 





 



Secondary Insurance

Yes No

 



 



 





 



 

Payment is due in full at the time of treatment

unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

 

 

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.



 
Medical History


Yes No




 


Good Fair Poor


Yes No


 


Yes No


Yes No


Yes No


 


Yes No


 

FOR WOMEN:


Yes No



Yes No

 

Have you ever had any of the following diseases or medical problems?

 


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No

 

 
 

Are you allergic to any of the following?

 


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No

 
Dental History
 

 


Yes No


Yes No

 


Good Fair Poor

 


Yes No


Yes No


Yes No


Hard Medium Soft


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No

 

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessarry dental services that I may need during diagnosis and treatment, with my informed consent.

 

 

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.



 
Medical History Update

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.


Yes No

 
 

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.