Medical History Update For Current Patients

Do you have an appointment?
- Yes
- No
Please call the office to make an appointment before completing the form.
Password
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Your Full Name*
Home Phone
Cell Phone
Home Address
City
State
Zip Code
Your Email Address
Child Information
Child's Full Name Actions
Edit

Delete
There are no Children.
Maximum number of children reached.
Has your child's dental insurance changed?
- Yes
- No
Primary Insurance Info
Employer Providing Insurance
Subscriber (covered employee)
Name of Insurance carrier (company)
Insurance ID number or badge number
Insurance Card Pictures
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Take a picture of the front and back of your card and upload here.
Secondary Insurance Info
If applicable
Employer Providing Insurance
Subscriber (covered employee)
Name of Insurance carrier (company)
Insurance ID number or badge number
Insurance Card Pictures
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Take a picture of the front and back of your card and upload here.
Topical fluoride applications are routinely done at every six-month preventative visit.
The American Academy of Pediatric Dentistry guidelines recommends the application of fluoride and dental examination every six-months; however, some insurance plans may only cover these services once a year. Please refer to your insurance handbook for coverage limitations.
Agree*
- By signing this form I agree that the information I provided is accurate to the best of my knowledge.
Signature

Medical History Update

Section Break

Child's Full Name	Actions
	Edit Delete
There are no Children.