Health History Update Form

Office of Keerthi Senthil DDS, MS

27700 Avenida Belleza, Cathedral City, CA - 92234, USA

760-318-4400

Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Physician Information. Please list all the physicians whose care you are currently under

Insurance Information. I certify that I or my dependants have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Medical Questions, general. Please indicate all that apply

If yes, please list all including vitamins, natural or herbals preparations and/or diet supplements or anything else the Dentist should be aware of:

Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction

Osteo-, Paget's, Other. Are you taking or scheduled to take either of the medications: Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis or Paget's disease?

Yes No Don't Know

Since 2001, were you treated or scheduled to intravenous bisphosphonates (Aredia/ Zometa) for osteoporosis, hypercalcemia or skeletal complications from Paget

Yes No Don't Know

Conditions, Diseases. Please indicate all that apply

Please list any and all Conditions or Diseases you may have, not listed here

*Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment.

I hereby 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 dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of 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.

Signature of Patient

Use your mouse cursor or the tip of your finger to sign above

Date: