Patient Information Form Page 3
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3Check if you have or have ever had any of the following:
Anemia
Cortisone Treatments
Hepatitis
Scarlet Fever
Arthritis, Rheumatism
Cough, Persistent
High Blood Pressure
Shortness of Breath
Artificial Heart Valves
Coughing Blood
HIV/AIDS
Skin Rash
Artificial Joints
Diabetes
Jaw Pain
Stroke
Asthma
Epilepsy
Kidney Disease
Swelling of Feet or Ankles
Back Problems
Fainting
Liver Disease
Thyroid Problems
Blood Disease
Glaucoma
Mitral Valve Prolapse
Tobacco Habit
Cancer
Headaches
Pacemaker
Tonsillitis
Chemical Dependency
Heart Murmur
Radiation Treatment
Tuberculosis
Chemotherapy
Heart Problems
Respiratory Disease
Ulcer
Circulatory Problems
Hemophilia
Rheumatic Fever
Venereal Disease
A
UTHORIZATION
I understand that the information that I have given today is correct to the best of my knowledge. I also
understand that this information will be held in the strictest of confidence and it is my responsibility to
inform the office of any changes in my medical status.
I hereby authorize the release of any information pertaining to my medical treatment necessary to
process any insurance claims. I further authorize the application for benefits on my behalf for covered
services and payment of any benefits to the office. I understand that I am responsible for any amount not
covered by insurance.
I understand that where appropriate, credit bureau reports may be obtained.
___________________________________________________________
___________
Patient Signature and/or Responsible Party
Date
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