1 form to complete.
Health History Update
Contact Information
Patient Information
Personal Information
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Male
Female
Date of Birth
Address
Address 2
Prov./State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If Referred, please provide name of person/business.
Emerg. Contact First Name
Emerg. Contact Last Name
Emerg. Relation
Phone
Contact Information
Do you have a benefit plan to cover dental work?
Yes
No
Do you have more than one dental benefits plan?
Yes
No
I understand that any portion not covered by my primary benefits plan is my responsibility to pay for at the time of treatment, and that Urban Smiles will submit paperwork for me to be reimbursed by my secondary benefits plan
Yes
No
Insurance Information
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Contact Information
Insurance Policy Limit
Recall frequency
Are white fillings on molars and eligible expense?
Medical History
Do you have any allergies?
Yes
No
If any, please list
Name of Physician
Name of Pharmacy
Have you experienced any unusual reaction to any of the following drugs?
Penicillin
Codeine
Aspirin
Local Anesthetic
NSAIDS (Ibuprofen)
Other
Please specify
Please list any medications you are currently taking
Are you taking Warfarin or Coumadin?
Yes
No
Are you currently or have you taken Fosamax
Yes
No
Have you ever had any of the following diseases / conditions?
Tuberculosis
Heart Disease
Mitral Valve Prolapse
Pacemaker
Diabetes
Hep A/B/C
Epilepsy
Joint / Valve replacement
Persistent cough
HIV
Are you allergic to Latex?
Yes
No
Details
Do you currently use Tobacco?
Yes
No
Details
Do you bruise easily; take a long time to heal from cuts?
Yes
No
Details
Women: Are you pregnant?
Yes
No
What is the due date?
Do you have any concerns that are not listed abouve that you feel we should know about? Please list.
Do you require extra freezing or premedication prior to dental appointments?
Yes
No
Details
Do you require Nitrous Oxide (laughing gas) prior to dental appointments?
Yes
No
Details