Medical Dental History Form
PATIENT
PARENT/GUARDIAN (for patients under 18)
CLOSEST RELATIVE
DENTIST
PHYSICIAN
GENERAL INFORMATION
FINANCIAL RESPONSIBILITY
DENTAL INSURANCE
MEDICAL INSURANCE
SECTION A- PATIENT HEALTH INFORMATION FOR PATIENTS OVER 18, PLEASE SKIP TO SECTION B FOR MINORS
MEDICAL HISTORY
DENTAL HISTORY
FAMILY MEDICAL HISTORY
SECTION B - PATIENT HEALTH INFORMATION FOR MINORS
MEDICAL HISTORY
MEDICAL HISTORY continued
DENTAL HISTORY
FAMILY MEDICAL HISTORY
RELEASE AND WAIVER
Health Care Privacy Act
- Treatment: means providing, coordinating, or managing health care related services by one or more health care providers.
- Payment: means using and disclosing your identifiable health information to obtain payment for services we provide to you, confirming coverage, billing and collection activities and utilization review.
- Health Care Operations: means using and disclosing your identifiable health information in connection with running of our practice, including quality assessment and improvement activities,
Patient/Parent/Guardian Signature

Patient/Parent/Guardian Signature