Health History Update Form

Today's Date

Patient Information

Patient Name

Date of Birth

Mailing Address

City

State

Zip

Phone #

Email Address

Medical Information

Are there any changes in your health?

Yes

If so, please specify

Physician's Name

Physician's Phone #

Are you allergic to Latex?

Yes

Do you need to be premedicated?

Yes

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

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Broken Appointments Form

It is extremely important to keep your appointment for your dental treatment since there will be an hour of the Doctor’s time scheduled exclusively for you. Caring Bear Dental is now charging a 50 Dollar Broken appointment fee for any treatments scheduled that are not Cancelled or Rescheduled on time. If you are unable to come in, please call our office at 818-284-4155 to cancel or reschedule your appointment at least 24-48 hours prior your appointment. Our office provides the opportunity to confirm your appointments by calling or texting our office one day before your scheduled appointment, please confirm your attendance by calling or texting us back before 3 PM. Otherwise your appointment may be cancelled in order to provide service to other patients in need of an appointment.

We thank you in advanced for your appreciation and respect of the Doctor’s time.