Submit Your Health History Form online to Dr. Smith's office

Save time at Dr. Smith's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate.

Patient Information

First Name

Last Name

What patient prefers to be called

Birth date

Home Phone

Work Phone

Cell/Other Phone

Email Address

If patient is a minor, give parent's or guardian's name

Social Security Number (U.S. only)

Gender

MaleFemaleOther

Address

Street

City

State/Province

Zip/Postal Code

Country

Whom may we thank for referring you to our office?

Other family members seen by us

Responsible Party Information

Full Name

Birth date

Home Phone

Work Phone

Cell/Other Phone

Address

Street

City

State/Province

Zip/Postal Code

Country

Email Address

Employer

Occupation

Spouse's Name

Birth date

Employer

Occupation

If patient is under 18, please complete this section.

Relationship to Patient

Do you have legal custody of this child?

YesNo

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician

Please check any of the following which apply to you, and add any relevant comments.

Are you taking any medication?

YesNo

Comment

Are you allergic to any medication?

YesNo

Comment

Are you allergic to latex?

YesNo

Comment

Do you have a history of any major illness?

YesNo

Comment

Have you had any major operations?

YesNo

Comment

Please check any of the following that you have had or currently have:

Abnormal bleeding/HemophiliaAnemiaArthritisAsthma or Hay feverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AidsKidney ProblemsPneumoniaNervous DisordersProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor or Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

General Dentist

What concerns you most about your teeth?

Do you have any type of thumb or tongue habit?

YesNo

Do you clench or grind your teeth?

YesNo

Dental Insurance Information

Insured's Name

Insured's Date Of Birth

Insured's Social Security Number (U.S. only)

Insurance Company

Group Number

Local Number

Phone Number

Insurance Company Address

Street

City

State/Province

Zip/Postal Code

Country

Do you have dual coverage?

YesNo

Insured's Name

Insured's Date Of Birth

Insured's Social Security Number (U.S. only)

Insurance Company

Group Number

Local Number

Phone Number

Insurance Company Address

Street

City

State/Province

Zip/Postal Code

Country

Emergency Information

Name of the nearest relative not living with you

Phone

Complete Address

Street

City

State/Province

Zip/Postal Code

Country

Signature:

Date

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.