www.gomezfamilydentist.com - Patient Information Form - 27 - 03 - 2023 

  • Medical History Update Form

    We are pleased to welcome you back to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

  • Patient Information
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency Contact
  • Format: (000) 000-0000.
  • Medical History
  • Format: (000) 000-0000.
  • Date of last visit
     - -
  • Have you ever had any serious illnesses or operations?*
  • Are you currently under physician care?*
  • Women Only
  • Are you pregnant?*
  • Nursing?*
  • Taking birth control pills?*
  • Check "Yes" or "No" if you have or have not had the following.
  • AIDS / HIV Positive*
  • Anaphylaxis*
  • Anemia*
  • Arthritis*
  • Artificial Heart Valves*
  • Artificial Joints*
  • Asthma*
  • Back Problems*
  • Blood Disease*
  • Cancer*
  • Chemical Dependency*
  • Chemotherapy*
  • Circulatory Problems*
  • Cortisone Treatments*
  • Persistent Cough*
  • Cough up Blood*
  • Diabetes*
  • Epilepsy*
  • Fainting*
  • Food Allergies*
  • Glaucoma*
  • Headaches*
  • Heart Murmur*
  • Heart Problems*
  • Herpes*
  • Hepatitis*
  • High Blood Pressure*
  • Jaw Pain*
  • Kidney Disease*
  • Liver Disease*
  • Latex Allergy*
  • Mitral Valve Prolapse*
  • Nervous Problems*
  • Osteoporosis*
  • Pacemaker / Heart Surgery*
  • Psychiatric Care*
  • Radiation Treatment*
  • Respiratory Disease*
  • Rheumatic Fever*
  • Scarlet Fever*
  • Shingles*
  • Shortness of Breath*
  • Skin Rash*
  • Spina bifida*
  • Stroke*
  • Surgical Implant*
  • Swelling of Feet and Ankles*
  • Thyroid Disease*
  • Tobacco use*
  • Tuberculosis*
  • Ulcer / Colitis*
  • Venereal Disease*
  • Other*
  • Authorization

  • I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and helpful dental treatment. If there is any change in medical status, I will inform the dentist.

    I authorize my insurance company to pay the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

    I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges not paid by insurance and that payment in full (Patient portion) is due at the time of treatment.

  • Date*
     - -
  • Should be Empty: