Medical Dental History Form
for Adult Patients

CONFIDENTIAL

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Signature

Signature

MEDICAL HISTORY UPDATES OR CHANGES

Signature

Dental Staff Signature

Signature

Dental Staff Signature

Signature

Dental Staff Signature