Ward Family Dental - Health History Update Form

Street Address

Street Address Line 2

CityState

Zip Code

Street Address

Street Address Line 2

CityState

Zip Code

*We must know your general health to take care of your dental needs. For your safety, please answer completely and correctly.

Actonel (risedronate) Oral dosageFosamax (alendronate) Oral dosageArendia (pamidonate) I.V. dosageZometa (zolendronic) I.V. dosageBoniva (ibandronate) Oral dosage

I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.

SpouseChild(ren)Information is not to be released to anyone.Other

I understand that I have the right to revoke this Authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to disclosure by the recipient and will no longer be protected by this rule. I understand that my health care provider cannot condition treatment on whether I sign this Authorization.

my homemy workmy cell

Please enter a valid phone number.

You may leave a detailed messagePlease leave a message asking me to return your callOther

Health History Update Form

For Insurance Purposes

Women

Medical Information Release and Authorization Form

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