PATIENT HEALTH HISTORY UPDATE FORM
CONFIDENTIAL INFORMATION
Please update your health history and note any changes since your last health history form was completed.
***We are especially concerned about any new allergies, heart conditions or reasons your dentist may prescribe any medications for you.
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.