Information Update Form

Information Update Form
Welcome back to our practice! This is our information update form. This is usually required when we haven't seen a patient in six months. We need to remain up-to-date with the patient's information so we may best serve them.

This will take 3-5 minutes of your time. Please fill it out as comprehensively as possible.
Which department of Let's Smile Dental do you have an appointment with?*
General Information
Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Do you have new Insurance?*

Only fill out if you have new insurance.
New Insurance Name
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Take Photo of front of insurance card
Take Photo of back of insurance card
Are you receiving text/email reminders of your appointments with our office?*

YesNo, and I would like to continue to opt out of text/email remindersNo, and I would like to opt in to receiving text/email reminders
Medical Update
Has the child ever had any of the following conditions?*

AutismADHDPregnancyAllergies to any drugsAny OperationsCancerHandicaps/DisabilitiesAllergies to any Latex ProductsHearing ImpairmentsAbnormal bleedingHemophilia/ Blood DiscordersHIV+/AidsConvulsions/EpilepsyTuberculosisAny Extended Hospital StaysAsthmaCongenital Birth DefectsRhematic/Scarlett FeverDiabetesHeart Disease/MurmurHepatitisKidney/Liver ConditionsNone of the above
Please discuss any serious medical conditions the child has had:
Please list all drugs, vitamins, and supplements the child is currently taking:
Please list all drugs the child is allergic to:
Child's Physician
Physician's Office Phone Number
Please enter a valid phone number.
Is the child currently under the care of a Specialist?
If so, please descibe the nature of this care
Please describe the child's current physical health:*
Doctor's Comments
Doctor Signature

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Guardian's Signature*

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Date*

MonthDayYear
Date
Should be Empty:

General Information