To ensure the highest quality of healthcare, we ask that you complete this patient update form.



Patient's Contact Information 

Email address: 

 

Phone number: 

 

Home address: 

Street address:

 

Apt/Suite/Other: 

Zip code: 

 

 

Pharmacy Information

Name:

 

Phone number: 

 

Address: 

 

Any changes to insurance? IF YES, PLEASE EXPLAIN.

Any change in medical history since last dental visit? IF YES, PLEASE EXPLAIN.

Any surgeries or hospitalizations since last dental visit? IF YES, PLEASE EXPLAIN.
Any change in dental health since last dental visit? IF YES, PLEASE EXPLAIN.

Any new family history of cancer or other health issues? IF YES, PLEASE EXPLAIN.

Are you taking any medications or supplements (prescription and/or non-prescription)? IF YES, PLEASE EXPLAIN.

Are you allergic to any medications, foods, or latex? IF YES, PLEASE EXPLAIN.

 

Do you use any tobacco products? IF YES, PLEASE EXPLAIN.

Females only: Are you pregnant? IF YES, PLEASE EXPLAIN.

Females only: Are you taking birth control? IF YES, PLEASE EXPLAIN.

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.