First Name *

Last Name

Phone *

Email *

If other, specify

Women Only

If you are pregnant or think you may be pregnant

If you are nursing

If you are taking birth control pills

Do you have any condition or problem, not listed, which we should know about? Please explain

Do you take antibiotic premedication before dental visits? *

Yes

Are you in good health? *

Yes

If you answered "no" to the question above, please explain: *

Please provide the name, address and phone number of your Physician:

Please list any medications you are currently taking

Authorization & Release

I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the Dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such dental care to third-party payors and or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my carrier may pay less than the actual bill for services. I agree to be responsible for all services rendered on my behalf or my dependents.

Signature_4 *

Clear

Use your mouse or finger to draw your signature above

I agree that the practice may send me Patient Care Related Messaging at the number I provided above. I understand my consent is not required for purchase. Messages Frequency will vary. Msg & data rates may apply. Reply HELP for help or STOP to cancel.

Medical History Update Form

Authorization & Release