New Patient Health History Form
Patient Information






 






 






 





 




 
Primary Insurance

Last Name, First Name, MI

 




 






 





 





 
Additional Insurance

Last Name, First Name, MI

 




 






 



 





 
Dental History




 




 

Please check all that apply:
















 
 
Medical History



 


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No

7. (Women) Are you:


Yes No


Yes No


Yes No

8. Have you had any allergic reactions to the following:


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


 

Please check all that apply:





















































Assignment and Release

I hereby authorize payment directly to for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

 
 

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.



 

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