Patient Update Form

Patient Medical History Update Form

First Name

Last Name

Date of Birth

EMERGENCY CONTACT

First Name

Last Name

Relationship to Patient

Telephone #

DENTAL HISTORY

Reason for today's visit

Date of Last Dental Care

Date of Last Dental X-Rays

How often do you floss?

How often do you brush?

Check if you have any problems with the following:

MEDICAL HISTORY

Physician's Name

Date of Last Visit

Have you had any serious illnesses or operations?

Yes No

If yes, please explain

Have you had a blood transfusion?

Yes No

If yes, please explain

Do you smoke?

Yes No

If yes, please explain

Do you consume alcohol?

Yes No

If yes, please explain

Do you use any recreational drugs?

Yes No

If yes, please explain

FOR WOMEN ONLY

Are you pregnant?

Yes No

If yes, number of weeks

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Do you have, or have had, any of the following?

AIDS

Yes No

Anemia

Yes No

Artificial Heart Valve

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Cancer

Yes No

Cerebral Palsy

Yes No

Chemical Dependency

Yes No

Chemotherapy

Yes No

CPAP Therapy

Yes No

Chronic Sinus

Yes No

Circulatory Problems

Yes No

Cortisone Problems

Yes No

Diabetes

Yes No

Epilepsy

Yes No

Excessive Bleeding

Yes No

Fainting

Yes No

Heart Murmur

Yes No

Heart Problems

Yes No

If yes, please describe

Hemophilia

Yes No

Hepatitis

Yes No

High Blood Pressure

Yes No

HIV Positive

Yes No

Jaw Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Mitral Valve Prolapse

Yes No

Nervous Problems

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory Disease

Yes No

Rheumatic Fever

Yes No

Shortness of Breath

Yes No

Sleep Apnea

Yes No

Snoring

Yes No

Tobacco Habit

Yes No

Tuberculosis

Yes No

Thyroid Problems

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

MEDICATIONS

ALLERGIES

FINANCIAL POLICY

If you do not have dental insurance:
• Payment is due at the time of service.

If you do have dental insurance:
• We will accept benefits for the amount covered by the insurance company. The part not covered by the insurance company is to be paid at the end of each appointment.

Cancellation Policy:

• I understand that if I cancel any dental appointment without giving 48 hours advance notice on a business day, I will be subject to paying $50 cancellation fee.

AUTHORIZATION

I authorize my insurance company to pay to the dentist or dental group 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.

Signature of Patient, Parent or Guardian

Clear

Clear

Date

** SCANNED COPY SERVES AS ORIGINAL **
PAYMENT IS DUE AT THE TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

Patient Medical History Update Form

EMERGENCY CONTACT

DENTAL HISTORY

MEDICAL HISTORY

FOR WOMEN ONLY

Do you have, or have had, any of the following?

FINANCIAL POLICY

AUTHORIZATION

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