Annual Patient Information Update

Patient First Name:
Patient Middle Initial:
Patient Last Name:
Patient Date of Birth:
Responsible Party First Name:
Responsible Party Middle Initial:
Responsible Party Last Name:
Current Address:
City:
State:
Zip:
Best phone number for calls/text:
Email:
Current Dentist Name:
Last Cleaning Date:
Please list any changes to your medical or dental history in the last year:
Please list any medications taken within the last year:
Current Dental Insurance Provider:
Insurance ID# or Subscriber Social Security #:
Group #:
Subscriber Name:
Subscriber Date of Birth:
Employer:
Acknowledgement and Receipt of Privacy Practices: This practice is required by federal law to maintain our patients’ privacy and provide them with access to the notice of our legal duties and privacy practices with respect to protected health information. Your signature below hereby acknowledges that you have reviewed our HIPAA Notice of Privacy Practices document and understand that you may obtain a copy for your records upon request.
(Must be signed by Parent or Guardian if patient is under 18.)
Patient/Parent/Guardian E-Signature:
Relationship to Patient:
Submission Date: