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Registration and Patient History Forms

The Registration form has areas to record the patient’s name, address, phone number(s), employer, Social Security number, insurance information, and a place for the patient’s signature to give authorization for treatment, and release of information.

Changes in history or medications can be recorded on the Medical History Update form.

The Dental History form is important because it records the patient’s purpose for the initial visit.

The Medical History form tracks vital information pertaining to adults. It is included in The Basic Record, The Complete Record, and The Flexible Record

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Wisconsin Dental Association, 6737 West Washington Street, Suite 2360, West Allis, WI 53214
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