Medical History Update

As a policy, we require our patients to update their medical history in its entirety annually as it is required by the MA Board of Registration in Dentistry. If you refuse to fill out this form, the practice reserves the right to dismiss you from the practice. All information is kept confidential.


Emergency Contact


Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company


Health History

PLEASE NOTE: If there has been a change that conflicts with our practices and you no longer require premedication, we require a note from your physician or surgeon to keep on file before you can be treated.


Have you had or do you currently have the following:


Medications


Allergies/ Reactions


For Women Only

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.


Form Completion

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. It is my responsibility to inform the dental office of any changes in my medical status and agree to updating my medical history when requested by the practice.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment due in full at the time of treatment.

If Patient is a Minor

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