Medical Update Form

Insurance Information

We submit to your insurance as a courtesy to you. In the event your insurance pays less than the estimated amount, you are responsible for the unpaid balance. All balances over 90 days will be subject to 1.5% (18%) monthly finance charge.

Primary Dental Insurance Company

Health History

For Women Only

Allergies/ Reactions


Form Completion

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

If Patient is a Minor

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