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INFORMATION UPDATE REQUEST

Patient Information Update Request

Let's update your Medical Information

Please provide the information below to request an update your medical information

Contact Us

First Name*

Last Name*

Middle Initial

Preferred Name

Family Status

Married

Single

Child

Other

Contact Information

Contact Information

Email*

Best time to call

Morning

Afternoon

Anytime

Home Phone Number

Cell Phone Number

Work Phone Number

Other Phone Number

Address

City

State

Zip Code

Employer Information

Employer Information

Employer Name

Primary Dental Insurance

Primary Dental Insurance

Full Name of Insured

Patient's relationship to insured

Self

Spouse

Child

Other

Insurance Plan Name

Secondary Dental Insurance

Secondary Dental Insurance

Full Name of Insured

Patient's relationship to insured

Self

Spouse

Child

Other

Insurance Plan Name

Medical Information

Medical Information

Please mark all medical conditions you have

Medical Info Checklist 1

*Pre-Med - Amox

*Pre-Med - Clind

*Pre-Med - Other

Acid Reflux

Allergy - Aspirin

Allergy - Codeine

Allergy - Erythro

Allergy - Hay Fever

Allergy - Latex

Allergy - Levoquin

Allergy - Macrobid

Allergy - Nuts

Allergy - Penicillin

Allergy - Seasonal

Allergy - Sulfa

Allergy -Amoxicillin

Allergy - Doxycycline

Allergy - Celebrex

Allergy - Ciprofloxacin

Allergy - Doxycycline

Allergy - Other

Anemia

Medical Info Checklist 2

Aneurysm

Angina history

Arthritis - Giant Cell

Arthritis

Artificial Joints

Arythmia

Asthma

Atrial Fibrillation

Augmentin

Back trouble

Blood Clots

Blood Disease

Cancer

CMT Disease

Congest. Heart Failure

COPD

Depression

Diabetes

Dizziness

Epilepsy

Essential Tremor

Excessive Bleeding

Medical Info Checklist 3

Fainting

Fibromyalgia

Glaucoma

Gout

Head Injuries

Heart Disease

Heart Murmur

Hepatitis

High Blood Pressure

High Cholesterol

HIV

Jaundice

Joint Replacement

Kidney Disease

Liver Disease

Lung Condition

Lupus

Macular Degeneration

Mental Disorders

Migraines

Mitral Valve Prolapse

Multiple Sclerosis

Medical Info Checklist 4

Nervous Disorders

Neuropathy

Osteoporosis

Pacemaker

Pregnancy

Radiation Treatment

Respiratory Problems

Restless Leg Syndrome

Rheumatic Fever

Rheumatism

Sinus Problems

Sleep Apnea/Snoring

Stomach Problems

Stroke

Thyroid Disease

TIA-Mini Stroke

Tuberculosis

Tumors

Ulcers

Venereal Disease

Other

See medication list

PRE-MED patients: please list why Pre-Med is needed

If there have been any medical changes since your last visit with us, please list below.

List all medications, drugs, pills or herbal remedies, including regular dosages of aspirin.

Opt-In

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly.

There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.

Thank you for updating your information.

We may follow up with you respectively.

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We are committed to serving our patients with the highest quality care available in a very relaxing and professional environment.

CONTACT

(425) 821-9600

12815 120th Ave. NE. Suite G. Kirkland, WA 98034

We are located conveniently at Evergreen Medical Dental Center just across from Evergreen Hospital and Bower in Totem Lake in Kirkland, WA. Steps away from Village at Totem Lake, Aspect Apartment and Condominiums, Jade Condominiums and north Totem Lake Apartments.

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