Health History Update

Health History Update

Please complete the patient information form below. Your details help us provide the best care possible.
Patient Information
Patient Name

First NameLast Name
Patient Birthdate

MonthDayYear
Date
The following information is for a(n):
Sex assigned at birth:
Gender Identity
Gender Identity write in
Preferred Phone Number for Communication
Please enter a valid phone number.Format: (000) 000-0000.
Agree to Receive Text Messages from LFO
Secondary Phone Number for Communication
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Email for Communication
example@example.com
Agree to Receive Email Communication from LFO
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact in case of Emergency (Name)
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Relationship to Patient
Dental Insurance
Do you have Dental Insurance?
Does this policy cover orthodontics?
Subscriber Name
Subscriber Birthdate

MonthDayYear
Date
Dental Insurance Company
Subscriber's Member ID (this may be your SSN)
Some insurances including Delta Dental, MetLife & Guardian use your Social Security Number as your member ID. Please provide SSN if a member ID is not listed on your card.
Group #
Subscriber's Relationship to patient
Please upload an image of the front of your insurance card

Cancelof
Please upload an image of the back of your insurance card

Cancelof
Do you have Secondary Dental Insurance?
Does the secondary policy cover orthodontics?
Secondary Subscriber Name
Secondary's Birthdate

MonthDayYear
Date
Secondary Dental Insurance Company
Secondary SSN/Member ID
Secondary Group #
Subscriber's Relationship to Patient
Please upload an image of the front of your secondary insurance card

Cancelof
Please upload an image of the back of your secondary insurance card

Cancelof
Patient Dental History
Do you have a Dentist?
Dentist's Name/Dental Office Name

Dentist's NameDental Office Name
Have there been any injuries to the face, mouth or teeth?
Explain your injury:
Have you had or do you presently have any of the following habits?
Are you aware of sores, lumps or irritated areas in the mouth?
Please Explain
Do you have any speech problems?
Have there been any changes to your dental health or dental treatment since your last visit? If yes, please explain.
Medical History
Are you taking any medication?
Medication Name(s):
Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)
List Allergies:
Have you had a serious illness or been hospitalized in the past year?
Please explain:
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?
Antibiotic Name and Method:
Do you use tobacco? (smoking, vaping or chewing)
If applicable, has the patient begun menstruation
Have you recently noticed a growth spurt?
Do you currently have any of the following conditions or take medication for any of the conditions below? (Please check if YES or leave unchecked for NO)
Other medical problems not listed:
Personal History Section
Name of School
Current Grade
Name of Employer
Job Title
Special Interests/Hobbies
Are there any updates to your life, family, dental, or medical history you’d like to share with us?
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION.
Signature
Patient/Parent's Signature
Should be Empty:

Health History Update

Patient Information

Dental Insurance

Patient Dental History

Medical History

Personal History Section