Health History Update Form

Welcome, todays visit the patient is scheduled for a “Growth and Development Exam”. As previously stated, this visit does not have an office fee for the exam. Should the patient be recommended for Extractions, CBCT scan, referral to specialist (ENT, TMJ, OS) or any recommended orthodontic treatment, we will recommend full diagnostic records on the patient.

The total fee for records is $445.00. This appointment will be an additional scheduled appointment: initials

This service may be billed to some insurances. We ask that you update our insurance/medical records yearly. Please take a moment to update our patient information document. If you have any questions, please see one of our receptionists.

Patient Name:

Date of Birth:

Phone#

Date:

Address:

City:

Zip:

Dentist:

Parent/Legal Guardian:

Address:

Phone#:

City:

Zip:

Email:

Financial responsible party:Parent/Legal Guardian:

Address:

Phone#:

City:

Zip:

Email:

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

Currently Medications:

Other medical conditions?

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

(Parent/guardian signature if patient is a minor (under age 18)

STAFF INITIALS INPUT FORM