ESTABLISHED PATIENT - DENTAL/MEDICAL HISTORY UPDATE
 

To ensure the highest quality of healthcare we ask that you complete this patient update form. Note: If patient has not been to our office in over 2 years a new complete medical history is required.

 
Today's Date:  
 
 





 
 

I CERTIFY that I have read and I understand the questions listed above. I have answered all of the questions to the best of my ability and my answers are correct. 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.

 

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