Form

PATIENT HEALTH HISTORY UPDATE FORM

CONFIDENTIAL INFORMATION

Today's Date

Patient's First Name

Patient's Last Name

Patient's Date Of Birth

Age

Address

City

Zip Code

Cell Phone

Home Phone

General Dentist

Responsible Party Email

Please update your health history and note any changes since your last health history form was completed.

Date of last history form update

***We are especially concerned about any new allergies, heart conditions or reasons your dentist may prescribe any medications for you.

Allergies:

Heart Conditions:

Medical Alerts and Medications

I have read and understood the above questions. I will not hold the orthodontist or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any additional changes later to this history record or medical/dental status, I will inform the practice.

Patient/Parent or Guardian Signature

Date Signed