Health History Update - RG

Form for:*

Child Adult

Patient's Name:*

Birthdate:*

Parent/Guardian Name:

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Best number to call to confirm:*

Best Phone # is:

Cell Home Work

Secondary Number:*

Secondary # is:

Cell Home Work

Email Address:*

Occupation*

Mother's Email Address:

Father's Email Address:

Would you like a text reminder 1 day prior to all appointments?*

Yes No

Text reminder phone number:*

Would you like an email reminder 2 days prior to all appointments?*

Yes No

Email Address:*

Patient's Dentist Name:

Do you have new dental insurance or any changes to your current dental insurance information?*

Yes No

Primary Insurance Co Name:*

Group #:

Ortho Coverage:

Yes No

Subscriber’s Name:*

Insurance Company Name:*

SSN/Member ID:*

Birthdate:*

Is the patient taking any medications?*

Yes No

Please list below.*

Are there any changes to your/your child's medical history*

Yes No

Changes/Comments:*

Has your child reached puberty?*

Yes No

What age*

Patient/Guardian Signature:*

[clear]

Use your mouse or finger to draw your signature above

Health/Dental History Update