Dental Medical History Form

PLEASE   L IST   A LL   M EDICATION   Y OU   A RE   C URRENTLY   T AKING   O R   H AVE   T AKEN   W ITHIN   T HE   L AST   2   W EEKS  

 

MEDICATION   N AME                                                                                                                             D OSAGE                                                                                               R EASON   F OR   T AKING                                                                                                 P RESCRIBING   P HYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date   o f   B irth:     _ ________________________________      

 

Height:     _ ___________         W eight:     _ ___________      

 

Current   P hysician’s   N ame:     _ ___________________________________________________________     A ddress:     _ ________________________________________________________________     P hone   # :     _ __________________________  

 

Specialist   P hysician’s   N ame:     _ _________________________________________________________     A ddress:     _ ________________________________________________________________     P hone   # :     _ __________________________  

 

Last   D entist’s   N ame:     _ ___________________________________________________________________     A ddress:     _ ________________________________________________________________     P hone   # :     _ __________________________  

 

AUTHORIZATION   A ND   R ELEASE  

I   c ertify   t hat   I   h ave   r ead   a nd   u nderstand   t he   a bove   i nformation   t o   t he   b est   o f   m y   k nowledge.     T he   a bove   q uestions   h ave   b een   a ccurately   a nswered.     I   u nderstand   t hat   p roviding   i ncorrect  

information   c an   b e   d angerous   t o   m y   h eath.     I   a uthorize   t he   d entist   t o   r elease   a ny   i nformation   i ncluding   t he   d iagnosis   a nd   t he   r ecords   o f   a ny   t reatment   o r   e xamination   r endered   t o   m e   o r   m y  

child   d uring   t he   p eriod   o f   s uch   d ental   c are   t o   t hird   p arty   p ayers   a nd/or   h ealth   p ractitioners.     I   a uthorize   a nd   r equest   m y   i nsurance   c ompany   t o   p ay   d irectly   t o   t he   d entist   o r   d ental   g roup  

insurance   b enefits   o therwise   p ayable   t o   m e.       I   u nderstand   t hat   m y   d ental   i nsurance   c arrier   m ay   p ay   l ess   t han   t he   a ctual   b ill   f or   s ervices.     I   a gree   t o   b e   r esponsible   f or   p ayment   o f   a ll   s ervices  

rendered   o n   m y   b ehalf   o r   m y   d ependents.  

 

Print   N ame:     _ _________________________________________________________________________________    

 

 

  R elationship   t o   P atient:     _ _________________________________________________  

 

 

Signature:     _ ______________________________________________________________   D ate:     _ _____________      

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________  

AREA   O NLY   F OR   D ENTAL   S TAFF  

SONICARE   M ODEL  

TYPE   O F   B LEACH  

OH   P RODUCTS   D ISPENSED  

PT.   P REFERENCES  

 

 

 

 

 

 

 

 

 

BLEACH   F OR   L IFE