Form

Medical History Update

Please update this form every six months

Patient's First Name

Last Name

Date Of Birth

Please provide your best contact phone number

Current Mailing Address

Do you have dental insurance?

If yes, We NEED you to provide us with the insurance carrier name(s) and subscriber ID number(s) below, for each of your current dental insurance plan(s). We also ask that you email a copy of the card(s) (front and back) to info@galesferrydentistry.com or text to 860-464-7204. If this is a new insurance plan, we will need the subscribers name and date of birth. It is VERY important we receive this information prior to your arrival.

Please list ANY medical conditions - including hospitalization's & surgeries

Do you have any known allergies or adverse reaction to drugs, food or environmental factors (including latex) ?

If yes, Please list:

Please list any medications the patient is currently taking, including over the counter medication.

Pharmacy Name:

Pharmacy Location City & State

Are You currently on a blood thinner? This includes Aspirin

If Yes, who is the prescribing doctor?

List blood thinner medication(s)

If prescribed, may we take X-Rays?

May we apply fluoride?

Please select your relationship to the patient

Patient/Legal Guardian Signature

Date