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Confidential Health History

Patient Information

Responsible Party

Insurance Information

I. Circle Appropriate Answer

(Leave blank if you do not understand the question)

If No

If No

If Yes

If Yes

If Yes

If Yes

II. Have You Ever Experienced Any Of The Following?

(Please circle Yes or No for each)

III. Have You Ever Had Or Do You Have Any Of The Following?

(Please circle Yes or No for each)

IV. Are You Allergic To Or Have You Had A Reaction To Any Of The Following?

(Please circle Yes or No for each)

V.Are You Taking Or Have You Taken Any Of The Following In The Last Three Months?

(Please circle Yes or No for each)

If Yes

VI. All Patients

(Please circle Yes or No for each, as applicable)

If Yes

If Yes

If Yes

If Yes

If Yes

If Yes

The practice of dentistry involves treating the whole person. If the dentist determines that there may be apotentially medically compromised situation, medical consultation may be needed prior tocommencement of dental treatment.

I authorize the dentist to contact my physician.

Date

3/13/2024

Authorization And Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above named dentist may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.

Date

3/13/2024

PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARANGEMENTS HAVE BEEN APPROVED.

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