Health History Form

1 | patient information

Name

FIRST

LAST

Date

Address

STREET ADDRESS

CITY

STATE / PROVINCE / REGION

POSTAL / ZIP CODE

COUNTRY

Cell Number

Home Number

Birthdate

Age

Gender

Male Female

General Dentist

Approximate date of last visit

What concerns you most about your teeth?

Whom may we thank for your visit today?

Is there anyone else in your family that is interested in having a free consultation?

2 | responsible party information

We do respect and protect your privacy.

Parent or Guardian Name

FIRST

LAST

Address

STREET ADDRESS

CITY

STATE / PROVINCE / REGION

POSTAL / ZIP CODE

COUNTRY

How long at address?

Home phone

Work phone

Cell phone

Social Security #

Birthdate

Relationship to Patient

Employer

Occupation

No. of years employed

Marital Status

Single Married Divorced Other

Spouse's Name

Employer

Occupation

No. of years employed

Social Security #

Birthdate

Work phone

3 | Dental Insurance Information

If you have dental insurance, please provide the following information so that we can verify your benefits before your scheduled appointment.

Member's Name

FIRST

LAST

Date of Birth

Insurance Company

Members Social Security #

Phone number

Contract #

Group or local number

Do you have dual coverage?

Yes No

1 | patient information

2 | responsible party information

3 | Dental Insurance Information

4 | Medical history

BENEFITS