Smith and Heymann - Health History Update Form

Health History Update Form
Patient's Name

First NameLast Name
Birthdate

MonthDayYear
Date
Parent/Guardian Name

First NameLast Name
Please update all information below.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best number to call to confirm
Please enter a valid phone number.Format: (000) 000-0000.
Best Phone # is
Secondary Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary # is
Email Address
example@example.com
Preferred way to receive reminders:
Would you like a text reminder 2 days prior to all appointments?
Would you like an email reminder 2 days prior to all appointments?
Patient's Dentist Name
Doctor Preference
Insurance Information
Do you have dental Insurance?
If yes, please provide details below.
Policy Holder's Name

First NameLast Name
Primary Insurance Co
Please provide state if Delta Dental is provider
Policy Holder's Employer
SSN/Member ID
SSN/Member ID
Do You Have Ortho Coverage?
Group #
Policy Holder’s Birthdate

MonthDayYear
Date
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance

If you have secondary insurance, please provide details below.
Do you have secondary insurance?
Policy Holder's Name

First NameLast Name
Policy Holder's Employer
Secondary Insurance Co
SSN/Member ID
Group #
Do you have orthodontic coverage?
Policy Holder's Birthdate

MonthDayYear
Date
Medical History
Is the patient's general health good at this time?
Comments
Is the patient under the care of a physician at this time?
If yes, please provide details
What is the name of your family physician?
Date of last physical

MonthDayYear
Date
Is the patient taking any medication?
If yes, please list below.
Are you allergic to any medication?
If yes, please list the names of medications the patient is allergic to
Has the patient ever taken any diet medication (Fen-Phen)?
Has the patient ever had a serious illness or been hospitalized?
If yes, please explain.
Has the patient had his/her tonsils and/or adenoids removed?
If yes, what age?
Does the patient have any special conditions not listed? If yes, please explain
Have the patient ever been advised by your physician to take an antibiotic prior to any dental treatments?
If yes, please provide antibiotic name and method.
Does the patient use tobacco? (smoking or chewing)
What is the patient's approximate height?
What is the patient's approximate weight?
HIPAA Consent
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address. I have read the HIPAA Policy and agree to the terms.
Patient/Guardian Signature
I give my consent to the orthodontic practice to use my cell phone to text information for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.
I give my consent to the orthodontic practice to text me for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.
Should be Empty:

Health History Update Form

Please update all information below.

Insurance Information

If yes, please provide details below.

Secondary Insurance

Medical History

HIPAA Consent