Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Have you had or do you currently have the following:


Form Completion

Section 32. 1-45. 1(A) and (B). Code of VA (1950, as amended) provides that in the event of significant exposure (e.g. needle stick) consent for testing for Human Immunodeficiency Virus (HIV), Hepatitis B Virus and Hepatitis Virus is considered to have been given by the patient and/or healthcare worker granting the hospital the right to perform such tests. Test results are confidential and can only be released in accordance with the applicable laws and the policy of the local hospital.

I acknowledge that I have reviewed ALL questions/ alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/ allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature.

If Patient is a Minor


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