Patient Information Update Form
Personal Information
First Name
*
Last Name
*
Cell Phone Number
*
Email Address
*
Birthday
Do you have a new address?
Yes
No
Add new address here:
Please update your emergency contact information:
Emergency Contact Name
Emergency Contact Phone
Changes to Employment & Insurance
Have you changed employers?
Yes
No
New Employer
Has your primary dental insurance changed?
Yes
No
Name of Insured
SS or ID No.
Relationship to Patient
Birthday
Employer
Insurance Carrier
Group Number
Has your secondary dental insurance changed?
Yes
No
Name of Insured
SS or ID No.
Relationship to Patient
Birthday
Employer
Insurance Carrier
Group Number
Changes to Health History
List all medication you are currently taking and why you are taking them:
Are you allergic to any of the following?
Latex
Codeine
Antibiotics (list below)
Dental anesthetics (list below)
List any other allergies:
Any changes in health status (hospitalizations, serious illness)?
Yes
No
Please describe health status changes:
Are you pregnant or nursing?
Yes
No
Are you taking birth control pills?
Yes
No
Do you smoke?
Yes
No
Do you have diabetes?
Yes
No
Do you get headaches?
Yes
No
Please indicate frequency & severity:
Headache Frequency
Headache Severity
Do you have any artificial joints?
Yes
No
Please indicate date placed:
Artificial Joints Date:
Do you snore, gasp for air, or wake up fatigued?
Yes
No
Describe anything specific you would like to talk to the doctor about today:
Sign & Date
Type Full Name Here
Today's Date
Notice of Privacy Practices
All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.
Uses and Disclosures
Your protected health information is accessed and used for healthcare related purposes only.
Your protected health information is never sold, rented, transferred, exchanged, and/or used for non-healthcare related purposes including marketing activities without your written authorization.
Your protected health information is disclosed to third-party entities without your written authorization for the purpose of treatment, to obtain payment for treatment, and for healthcare operations.
Certain Circumstances
Your protected health information can be disclosed without your written authorization in certain limited circumstances,
Medical emergencies
In situations required by law
Individuals involved in your care
When requested by public health agency
When requested by a law enforcement agency
For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.
Patient Rights
You have the right to request in writing to inspect and/or receive a copy of yourhealth information. *
You have the right to request an alternate means or location to receive communications regarding your health information. *
You have the right to request in writing to amend, correct, or delete any recorded health information within our possession. *
You have the right to request in writing to restrict some of the uses and disclosures of your health information. *
You have the right to request in writing an accounting of certain disclosures of your health information that were made by this office. *
* Conditions and limitations may apply; obtain additional information from front desk.