Patient Information Update Form

Please fill out this form to update your information.

ABOUT YOU

Name:*

First Middle Last

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone #:

Work Phone #:

Cell phone #:

Email address:*

INSURANCE INFO

For insurance changes please contact our office at (360) 696-4439.

MEDICAL HISTORY

Are you under a physician's care now?*

Yes
No

If yes, please explain:

Have you ever been hospitalized or had a major operation?*

Yes
No

If yes, please explain:

Have you ever had a serious head or neck injury?*

Yes
No

If yes, please explain:

Are you taking any medications, pills or drugs?*

Yes
No

If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?*

Yes
No

If yes, please explain:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

Yes
No

If yes, please explain:

Do you use tobacco?*

Yes
No

If yes, please explain:

Do you use controlled substances?*

Yes
No

If yes, please explain:

Do you use marijuana?*

Yes
No

If yes, please explain:

WOMEN:

Are you Pregnant/Trying to get pregnant?

Yes
No

Taking Oral Contraceptives?

Yes
No

Nursing?

Yes
No

Do you take herbal supplements or other OTC products ex: fish oil or vitamins?*

Yes
No

If yes, please list:

Are you allergic to any of the following?*

If yes, please explain:

Are you allergic to anything not listed? Please specify.

Do you have, or have you had, any of the following?

AIDS/HIV Positive*

Yes
No

Alzheimer's Disease*

Yes
No

Anaphylaxis*

Yes
No

Anemia*

Yes
No

Angina*

Yes
No

Anxiety*

Yes
No

Arthritis / Gout*

Yes
No

Artificial Heart Valve*

Yes
No

Artificial Joint*

Yes
No

Asthma*

Yes
No

Blood Disease*

Yes
No

Blood Transfusion*

Yes
No

Breathing Problem*

Yes
No

Bruise Easily*

Yes
No

Cancer*

Yes
No

Chemotherapy*

Yes
No

Chest Pains*

Yes
No

Cold Sores / Fever Blisters*

Yes
No

Congenital Heart Disorder*

Yes
No

Cortisone Medicine*

Yes
No

Depression*

Yes
No

Diabetes*

Yes
No

Drug Addiction*

Yes
No

Emphysema*

Yes
No

Epilepsy or Seizures*

Yes
No

Excessive Bleeding*

Yes
No

Excessive Thirst*

Yes
No

Fainting Spells / Dizziness*

Yes
No

Frequent Cough*

Yes
No

Frequent Headaches*

Yes
No

Dementia*

Yes
No

Glaucoma*

Yes
No

Hay Fever*

Yes
No

Heart Attack / Failure*

Yes
No

Heart Murmur*

Yes
No

Heart Pacemaker*

Yes
No

Heart Trouble / Disease*

Yes
No

Hemophilia*

Yes
No

Hepetitis A*

Yes
No

Hepetitis B or C*

Yes
No

Herpes*

Yes
No

High Blood Pressure*

Yes
No

High Cholesterol*

Yes
No

Hives or Rash*

Yes
No

Hypoglycemia*

Yes
No

Irregular Heartbeat*

Yes
No

Kidney Problems*

Yes
No

Leukemia*

Yes
No

Liver Disease*

Yes
No

Low Blood Pressure*

Yes
No

Lung Disease*

Yes
No

Mitral Valve Prolapse*

Yes
No

Osteoporosis*

Yes
No

Pain in Jaw Joints*

Yes
No

Parathyroid Disease*

Yes
No

Parkinson's Disease*

Yes
No

Psychiatric Care*

Yes
No

Radiation Treatments*

Yes
No

Renal Dialysis*

Yes
No

Rheumatic Fever*

Yes
No

Rheumatism*

Yes
No

Scarlet Fever*

Yes
No

Shingles*

Yes
No

Sickle Cell Disease*

Yes
No

Sinus Trouble*

Yes
No

Spina Bifida*

Yes
No

Stomach / Intestinal Disease*

Yes
No

Stroke*

Yes
No

Thyroid Disease*

Yes
No

Tonsillitis*

Yes
No

Tuberculosis*

Yes
No

Tumors or Growths*

Yes
No

Ulcers*

Yes
No

Venereal Disease*

Yes
No

Have you ever had any serious illness not listed above?

Yes
No

Comments:

Please check the required boxes:*

Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
I understand that if I am not able to keep an appointment I am required to inform Fujioka Family Dentistry at least 24 hours in advance. If 24 hour notice is not given, I will be charged a $50 cancellation fee.

I acknowledge that I have reviewed the Statement of Privacy Practices

I have read the Statement of Privacy Practices*

Signature (Please Type Full Name):*

Adult Patient
Parent or Guardian
Spouse

Date*

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