Download Please take a moment to help us maintain the most up to date

Please take a moment to help us maintain the most up to date information on the
patient.
Patient Name:
Date:
Name of Person Completing this form:
Relationship to Patient:
Mailing Address:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Other Number:
Email Address:
Please list and explain any recent hospitalizations, out-patient surgeries, sicknesses,
doctor visits or changes in medical history.
Please list ALL current medications the patient is taking including both prescription
and over the counter.
Are you pleased with the new methods of text and email to confirm the patient’s
appointment? We also welcome your preferences and suggestions.
______________________________________________________________________________
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We thank you for your confidence in us and look forward to providing the highest
quality of care in a relaxed and loving environment for each patient. If you have a
friend or family member looking for a dental home we would appreciate your
recommendation and referral. Please make sure they let us know you referred them
and we thank you in advance.