Patient Information Update

We are committed to excellence in dentistry and appreciate you being one of our existing patients. This form allows us to update your general demographics, and medical or dental changes that may have occurred since your last visit. If you have any questions please feel free to ask!

Name Name * First Last
I preferred to be called I preferred to be called First Last
Sex

Sex Male Female
Check Appropriate Box

Check Appropriate Box Minor Single Married Divorced Widow Separated
Date of Birth Date of Birth * / MM / DD YYYY
Age
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Phone Primary Phone * - ### - ### ####
Primary Phone Type *
Secondary Phone Secondary Phone - ### - ### ####
Secondary Phone Type
Additional Phone Additional Phone - ### - ### ####
Additional Phone Type
Email *
Employer
How long there?
Occupation
Employer's Address Employer's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Dental Insurance Information

Primary Insurance
Insurance Company Name *
Phone Phone * - ### - ### ####
Group Policy Number
Policy Holder's Name Policy Holder's Name * First Last
Policy Holder's Date of Birth Policy Holder's Date of Birth * / MM / DD YYYY
Policy Holder's Social Security Number/Insurance ID Number *
Relation
Policy Holder's Employer *
Policy Holder's Home Address, if different
Secondary Insurance
Insurance Company Name
Phone Phone - ### - ### ####
Group Policy Number
Policy Holder's Name Policy Holder's Name First Last
Policy Holder's Date of Birth Policy Holder's Date of Birth / MM / DD YYYY
Relation
Policy Holder's Social Security Number/Insurance ID
Policy Holder's Employer
Policy Holder's Home address, if different
Confidential Health History

Please note any changes to your medical history since your last visit.
1. Is your general health good? *

1. Is your general health good? Yes No
If no, please explain
Has there been a change in your health within the last year? *

Has there been a change in your health within the last year? Yes No
If yes, please explain
Please list ALL medications being taken currently (including prescription, OTC, vitamins and supplements) *

Please type "NONE" if not currently on medication.
WOMEN ONLY

Select Yes or No for each
Are you or could you be pregnant? *

Are you or could you be pregnant? Yes No

If yes, please have an OB-GYN dental release prior to visit.
If yes, when are you due?
Are you nursing?

Are you nursing? Yes No
Are you taking birth control?

Are you taking birth control? Yes No
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform Dr. Flores & staff of any change in my health and/or medication. Further, I will not hold Dr. Flores or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient (Parent or Guardian) - Draw your signature into the box below *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date * / MM / DD YYYY

Patient Information Update

Patient Information Update

Dental Insurance Information

Confidential Health History

WOMEN ONLY