Health History Update Form
Patient's Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Please update all information below.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best number to call to confirm
*
Please enter a valid phone number.
Best Phone # is
*
Home
Cell
Work
Secondary Number
Please enter a valid phone number.
Secondary # is
Home
Cell
Work
Email Address
example@example.com
Preferred way to receive reminders:
Text
Email
Both
Would you like a text reminder 2 days prior to all appointments?
Yes
No
Would you like an email reminder 2 days prior to all appointments?
Yes
No
Patient's Dentist Name
Doctor Preference
Please Select
Dr. Smith
Dr. Heymann
Dr. Skillestad
Insurance Information
Do you have dental Insurance?
*
Yes
No
If yes, please provide details below.
Policy Holder's Name
First Name
Last Name
Primary Insurance Co
Please provide state if Delta Dental is provider
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Policy Holder's Employer
SSN/Member ID
SSN/Member ID
Do You Have Ortho Coverage?
Yes
No
Group #
Policy Holder’s Birthdate
-
Month
-
Day
Year
Date
Insured's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insurance
If you have secondary insurance, please provide details below.
Do you have secondary insurance?
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Employer
Secondary Insurance Co
SSN/Member ID
Group #
Do you have orthodontic coverage?
*
Yes
No
Policy Holder's Birthdate
*
-
Month
-
Day
Year
Date
Medical History
Is the patient's general health good at this time?
*
Yes
No
Comments
Is the patient under the care of a physician at this time?
*
Yes
No
If yes, please provide details
What is the name of your family physician?
Date of last physical
-
Month
-
Day
Year
Date
Is the patient taking any medication?
*
Yes
No
If yes, please list below.
Are you allergic to any medication?
*
Yes
No
If yes, please list the names of medications the patient is allergic to
Has the patient ever taken any diet medication (Fen-Phen)?
*
Yes
No
Has the patient ever had a serious illness or been hospitalized?
*
Yes
No
If yes, please explain.
Has the patient had his/her tonsils and/or adenoids removed?
*
Yes
No
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?
*
Yes
No
If yes, please provide antibiotic name and method.
Does the patient use tobacco? (smoking or chewing)
*
Yes
No
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.
*
Agree
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 agree
I disagree
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.
*
I agree
I disagree
Submit
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