History Update

Established Patient - Dental/Medical History Update

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

Note: If the patient has not been to our office in over 2 years, a new complete medical history is required.

Today's Date:

Patient First Name

Last Name

Patient Date of Birth

Parent/Guardian First Name

Last Name

Preferred Contact Phone #

I hereby certify that I have thoroughly read and understood all questions presented. I have provided answers to the best of my knowledge, ensuring their accuracy and completeness. I acknowledge that I will not hold my doctor or any staff member accountable for any inaccuracies or omissions resulting from my responses on this form

Signature of Parent/ Guardian (Patient if over the age of 18yrs)

Date: