Medical Update

Medical Update Form

Patient First Name

Patient Last Name

Date of Birth

Email

Cell Phone

Work Phone

Home Phone

Address

City

State

Zipcode

Insurance Information

Has there been any change in dental insurance since your last visit?

Yes No

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

Primary Policy Holder

Relation

Gender

Male Female

Date of Birth

SSN

Insurance Company Name

Telephone

Insurance Company Address

City

State

Zip Code

Group #

Member ID#

Health History

Are you under the care of a physician?

Yes No

Date of last visit?

Physician Name

Physician Phone

Any hospitalization, surgeries or serious illnesses in the past?

Yes No

Please explain

Any history of head & neck radiation?

Yes No

For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, number of weeks

Allergies/ Reactions

Please list any allergies/ allergic reactions.

Medications

Please list any medications you are currently taking below.

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.

Signature of Patient or Guardian

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient:

Medical Update Form

Insurance Information

Primary Dental Insurance Company

Health History

For Women Only

Allergies/ Reactions

Medications

Form Completion

If Patient is a Minor

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