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Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (?rst and last): Name of previous dentist/location: Date of last dental examination: Date.

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Including, as appropriate: personal information such as name, date of birth and address. histories (medical, dental and social) presenting complaints. dental charting, including indices such as BPE, BEWE, etc. findings on examination, including negative findings (eg, soft tissues, nothing abnormal)

The dental record is also a legal document that can be the single most important source of supporting evidence in a liability claim or board of dentistry complaint.

Dental records, also known as patient charts, are made up of the recorded information regarding your medical history, diagnostic information, clinical notes, patient-doctor communication, consent to treatment documents and treatment notes, as the American Dental Association (ADA) explains.

Handwritten entries should be legible. Identification data — name, date of birth, phone numbers, and emergency contact information. No financial information should be kept in the dental record.

Accurate general patient information which includes the patient's full name, address and contact details. It should also include the time and date of the patient's visit. A detailed record of the patient's medical history should be made. The practitioners should be satisfied that the information is correct.

Information that should not be noted in the dental record includes: any financial information, including ledger cards, insurance benefit breakdowns, insurance claims, and payment vouchers. The patient's financial records are not part of the clinical record and should be maintained separately.

Some of the issues that can be covered in a health history form include: The patient's health conditions and illnesses. Contact information for the patient's primary health care provider and/or any specialists coordinating specific medical treatment. Current medications that the patient is taking.

Information typically noted in the dental record includes: personal data, such as the patient's name, birth date, address and contact information including home, work and mobile telephone numbers. the patient's place of employment. medical and dental histories, notes and updates. progress and treatment notes.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232