Medical History Update Form

Address (if changed)

Phone # Work Phone #

Person to contact in an emergency Phone #

Insurance (if changed)

Personal Physician's Name

The approximate date of your last doctors visit

Your current physical health is

Good

Fair

Poor

Are you currently under the care of any physician?

Yes

If yes, please explain

Do you smoke or use tobacco in any other form?

Yes

Are you presently taking any drugs prescribed by a physician or dentist?

Yes

Are you taking aspirin?

Yes

Are you taking blood thinners?

Yes

Are you pregnant?

Yes

Are you taking birth control pills?

Yes

Have you been told that you need to take antibiotics before any dental procedure?

Yes

Have you had any serious medical problems in the last 5 years?

Yes

Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.

AT LEAST 48 HOURS NOTICE MUST BE GIVEN IF CANCELLATION IS ABSOLUTELY NECESSARY, OTHERWISE A CANCELLATION CHARGE OF $75.00 WILL BE MADE.

Have you ever had any of the following diseases or medical problems?

Have you experienced any that are not listed above

Yes

Are you allergic to any of the following?

Penicillin

Dental Anesthetics

Latex

Aspirin

Tetracycline

Metals

Acrylics

Opioids like Codeine/Hydrocodone

Are you allergic to any other drugs?

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical statue.

By clicking here I agree that my name on this form constitutes a legal signature