Health History Update - RG Header Image

Health/Dental History Update

Form for:*
Best Phone # is:
Secondary # is:
Would you like a text reminder 1 day prior to all appointments?*
Would you like an email reminder 2 days prior to all appointments?*
Do you have new dental insurance or any changes to your current dental insurance information?*
Ortho Coverage:
Is the patient taking any medications?*
Are there any changes to your/your child's medical history*
Has your child reached puberty?*
Use your mouse or finger to draw your signature above