Health History Update
First Name:
Middle Initial:
Last Name:
Birthdate:
Have there been any changes to the patient's medical history in the last year?
No
Yes
Please list significant medical history below:
Have there been any changes to the patient's dental insurance?
No
Yes
If yes, please provide the updated insurance information to the front desk.
Has any of your contact information changed?
No
Yes
If yes, please list updated contact information below:
Responsible Party Name:
Relationship to Patient:
Responsible Party Signature:
Date: