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.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Do 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.Format: (000) 000-0000.
- 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
- Guardian's Signature*
- Date*
  
  MonthDayYear
  Date
- Should be Empty:

Information Update Form

General Information

Medical Update