Medical Update Form

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Dental History

Medical History

Have you had or do you currently have the following:


Please list all medications, over the counter and herbal supplements, that you are currently taking
(include medication name, dosage and frequency):

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following?

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 affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover.

If Patient is a Minor

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