MEDICAL HISTORY FORM

  • MEDICAL HISTORY

    Please complete the following questions so that we may thoroughly diagnose your condition. The information you provide is for our records and will be considered strictly confidential. In addition, it is your responsibility to update this medical history when any changes occur.
  • Women:

  • If yes to taking birth control pills, be advised that if you take antibiotics, an alternative method of birth control must be used.

  • All of the above information is true to the best of my knowledge.

  • Date Format: MM slash DD slash YYYY
  • PATIENT INFORMATION

  • PRIMARY INSURANCE

  • Secondary Insurance

  • Method of Payment

  • Method of Payment:
  • Signature
  • Date Format: MM slash DD slash YYYY
  • If dental insurance applies: Although this office files insurance claims as a service to the patient, the insurance contract is between the patient and the insurance company. As we have no control over the insurance company's method of payment or amount of payment, any difference of payment is entirely the responsibility of the patient.