Belleville ADULT Medical History Form

Medical & Dental History

Please take a moment to tell us about your medical and dental history so that we can serve you as effectively as possible. Your information is being stored securely.
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Patient Info
Patient Name*

First NameMiddle NameLast Name
Health Card Number
Date of Birth

MonthDayYear
Date
Biological Sex*

MaleFemale
Email Address*
NOTICE

Please ensure you have been given the correct form!

This form is intended for use by adults only. If you need the form for your child/dependent, please contact the Belleville FDC Office at (613) 961-7050.
*

I am NOT filling this form out on behalf of a child.
NOTICE

This form is not intended to be filled out by or on behalf of minors. Please correct your date of birth above or contact Belleville FDC at (613) 961-7050 before continuing.

Final Page
Do you have any other questions or concerns?
If you could change anything about your mouth, teeth, or smile, what would it be?*
Authorization
*

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health I will inform the office at my next dental appointment without fail.
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practicioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice and for it to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agreeto be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
Patient Signature*

Clear
Date*

DayMonthYear
Date
FOR OFFICE USE ONLY
Dentist's Notes
Dentist Signature

Clear
Dentist Signature Date*

DayMonthYear
Date
Should be Empty:

Medical & Dental History

Patient Info

General Health

Medical Conditions

Dental Info

Final Page

Authorization

FOR OFFICE USE ONLY