Get Tx Wichita Falls Endodontics Patient Information & Health History 2013-2025

Completing the TX Wichita Falls Endodontics Patient Information & Health History form online is a straightforward process designed to ensure that your dental care is tailored to your unique health needs. This guide will walk you through each section of the form, providing clear instructions to make the process as smooth as possible.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the Patient Information & Health History form and open it for editing.
2. Begin by entering today's date in the specified field.
3. Fill in your full name, including first, middle, and last names.
4. Provide your residential address, including city, state, and zip code.
5. Enter your home and cell phone numbers.
6. Input your social security number and sex.
7. Indicate your marital status and employer's name, along with the employer's address.
8. Fill in the business phone number and your email address.
9. Enter your date of birth and spouse's name, if applicable.
10. Your present position should be filled out in the specified section.
11. In case of emergency, provide the names, phone numbers, and relationships of persons to be contacted.
12. Specify the name of your dental provider.
13. Next, provide your dental insurance information, including the insurance company’s name, phone number, and address.
14. Fill in the name of the insured person, group number, and the effective date of the insurance.
15. In the medical information section, list the name of your physician and indicate your current physical health status (good, fair, or poor).
16. Answer whether you are under the care of any physician, and explain if the answer is yes.
17. Indicate if you smoke or use tobacco and if you are taking any prescribed medications. List any medications if applicable.
18. Women should answer if they are pregnant and provide the number of weeks pregnant.
19. State whether you have ever been premedicated before dental treatment.
20. Indicate if you have been hospitalized or experienced serious medical problems in the last five years, providing explanations if applicable.
21. Answer the questions regarding any past diseases or medical problems by checking yes or no.
22. Indicate allergies to drugs, if any, by checking the corresponding boxes.
23. In the acknowledgement and authority section, authorize payment for dental benefits directly to Wichita Falls Endodontics.
24. Sign and date the form, indicating whether you are signing as a patient or as a guardian for a minor.
25. Once all information is complete, save changes, and download, print, or share the completed form as needed.

Start filling out your TX Wichita Falls Endodontics Patient Information & Health History form online today!