Medical History and Insurance Form

Patient Name

First

Last

please or dosages

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Any changes in your insurance?

Any changes in health since your last dental visit?

Any surgeries or hospitalizations since your last dental visit?

Are you allergic to anything?

Please list ANY/ALL CURRENT MEDICATIONS and dosages (if none, put "none or N/A"

Patient/Carer/Guardian Signature

Clear Signature

Date