Health History Update Form

At todays visit the patient is scheduled for a: "Growth and Development appointment" this visit to see the Doctor is complimentary. We scheduled a patient to the development to prepare for the need of Orthodontic treatment. In the event that the doctor may need to have a diagnostic radiograph taken maybe a fee accessed prior to taking this image. We ask that you update our insurance/medical records on a regular basis. Please take a moment to update our patient information document. If you have any questions, please see one of our receptionist. Please beware that we are working in the ERA of COVID-19 and that we have made several new office policy changes in regards to visitors and selective procedure types. Thank you

Patient Name:

Phone#

Date:

Address:

City:

Zip:

Family Dentist:

When was your last check-up (teeth cleaning)?

Parent Name:

Email:

Please grant permission for us to communicate via TEXT service

Yes No

Primary Orthodontic Insurance:

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #

Group # (Plan, Local or Policy):

Policy Owner's Name:

Policy Owner's Birthdate:

SSN#

Employer Name:

Secondary Orthodontic Insurance: (Assign to Subscriber)

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #

Group # (Plan, Local or Policy):

Policy Owner's Name:

policy Owner's Birthdate:

SSN#

Employer Name:

MEDICAL - DENTAL HISTORY

Please list medications that the patient is currently taking:

Other medical conditions?

Sgnature of patient (Parent/Guardian if patient is under age 18)