Medical History Form printable pdf download

Medical History Form

We Respect Your Privacy

In order to provide you with the highest standard of dental care, this practice is

required to collect personal information from you. This information covers your

medical history and personal contact details. Without this general health picture, the

treating dentist is unable to plan your dental care properly.

Naturally some of this information is of a personal nature and some of it may be

regarded as sensitive. This information will only be used by the treating dentist in

order to deliver your dental care to the highest standards.

Title: Mr / Mrs / Miss / Ms

Last Name:

First name:

Preferred Name:

Date of Birth:

Home Address:

Email Address:

Telephone( Home):

Emergency Contact Name:

Mobile:

Emergency Contact Number:

Work:

Private Health Insurance: Yes / No

Department of Veteran Affairs I.D.

( if applicable)

Name of Fund:

Number on Card:

Patient Id:

How did you hear about us?

PLEASE TURN OVER AND COMPLETE

File Number (Office Use only)

Medical History Form