Medical/Dental History Update or Changes

(Required every 12 months or when changes occurs)
First Name:
Last Name:
Birthdate:
Is the patient taking prescription medication, nutrients, supplements, herbal medications or non-prescription medicine?
Please list them:
Medication 1:
Taken For:
Medication 2:
Taken For:
Medication 3:
Taken For:
Medication 4:
Taken For:
Do you have any allergies to food, medications, or metals?
Please list them:
Allergy 1:
Allergy 2:
When was your last dental exam?
When was your last dental cleaning?
Are there any changes or modifications to the patient's health/dental history that we should be aware of?
What is the patient's current contact information:
Age:
Email:
Address:
City:
State:
Zip:
Home #:
Cell Phone:
IF PATIENT IS A CHILD:
Parent Cell #:
Email:
ADULTS:
Occupation:
Employer:
Wk Phone #:
Signature:
Date Signed:
I am the:

Insurance Information

Has your insurance changed this year for the following upcoming year?
Insurance Name:
Subscriber ID:
Subscriber DOB:
Relationship to Patient:
Effective Date: