Hanson Yearly Update Information Form

General Release
I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information. in the medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided form or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.*

I Understand
Patient's Signature*

Clear
Patient's Name*

First NameMiddle NameLast Name
Responsible Party's Signature*

Clear
Responsible Party's Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

	Yes	No
Heart Attack
Stroke / TIA
Pacemaker
Angina / Chest Pain
Stents Placed
Congestive Heart Failure
Infective Endocarditis / Rheumatic Heart Disease
Prosthetic Cardiac / Heart Valve
Prosthetic Joint Replacement

Insurance