Medical History Update

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

7 Gramercy Park West
New York, NY 10003
+1 (212) 777-7126
This online form is primarily for print only, so you can:
1. Fill out information online, print out the completed form, and sign it at our office; or
2. Print out a blank form, fill it out and sign it at our office; or
3. Fill out the forms that we have in the office and sign there.
MEDICAL HISTORY UPDATE
Date
MM slash DD slash YYYY
Patient Name
First Middle Last
Home Phone
Mobile Phone
Email
Has there been any change in your health since your last dental appointment here?
- Yes
- No
If "Yes" what condition(s)?
Are you taking any kind of medication at this time?
- Yes
- No
If "Yes" what medication(s)?
Do you have any allergies (or adverse reactions) to any medications?
- Yes
- No
If "Yes" what medication(s) are you allergic to?
Change of Address
If there has been an address change since your last visit here, please detail below.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Signature

Doctor Signature

$250 Dental Cleaning, X-rays & Exam