• Medical History Form

  • Welcome!

  • About You

  • Todays Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Birth date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Person Responsible for Account if other than yourself

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Spouse Information

  • Do you have a spouse?
  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Insurance Information

  • Primary Insurance

  • Does the patient have insurance?
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Secondary Insurance

  • Does the patient have insurance?
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Medical History

  • Do you have a personal Physician?*
  • Format: (000) 000-0000.
  • Date of Last Visit*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your current physical health is?*
  • Are you currently under the care of a physician?*
  • Do you smoke or use tobacco in any other form?*
  • Have you ever taken Phen-Fen? (Also known as Redux or Pondimin)*
  • Have you ever taken Fosamax, or any other bisphosphonate?*
  • Allergies
    Rows

  • For Women

  • Are you a women?
  • Are you pregnant?
  • Are you nursing?
  • Are you taking any of the following?
    Rows
  • Do you or have you experienced the following?
    Rows

  • Dental History

  • Are you currently in pain?*
  • Have you experienced problems associated with any previous dental work?*
  • Your current dental health is?*
  • Brush daily?*
  • Type of bristles on your toothbrush?*
  • Do you use anything in addition to your brush and floss?
  • Would you like fresher breath?*
  • Whiter teeth?*
  • Do you gums ever bleed?*
  • Have you ever had periodontal disease?*
  • Do you have mobility in your teeth?*
  • Are you happy with the way your smile looks?*

  • Authorizations

  • I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Payment is Due at Time of Service

  • I certify that I am covered by Insurance Co. and I assign directly to Dr. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: