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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

Signature

Signature

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,

Signature

Patient/Parent/Guardian Signature

Patient/Parent/Guardian Signature