Adult Patient Health History Form

Adult Patient Health History Form

Please complete this health history form for your dental care at Believe Dental Care. Your information is kept confidential and HIPAA-compliant.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician
Medical History
Select any medical conditions you have or have had:

Other
Current Medications (please list all)
Allergies (please list all allergies, including medications, foods, etc.)
Dental History
Select any dental issues you have or have had:

Other
Insurance Information
Insurance Provider
Policy Holder Name

First NameLast Name
Policy/Member ID
Group Number
Signature (Type or Draw Your Name to Authorize)
Date

MonthDayYear
Date
Should be Empty: