OBS 2 Health History Form

"*" indicates required fields

Patient Information

Name*

First Last

Preferred Name/Nickname

Gender*

If patient is a child, who is accompanying them?

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dentist Name*

First & Last

Date of Last Visit

Responsible Party Information

*The Responsible Party is the person bringing the patient to their appointment and will be responsible for signing all forms.

Patient is Responsible Party (Skip if checked)

Name

First Last

Birthday

Primary Phone Number

Relationship to Patient

Occupation

Employer

# Years Employed

Spouse's Name

First Last

Birthday

Relationship to Patient

Occupation

Employer

# Years Employed

Dental Insurance Information

Check this box if you will be “Self Pay”

Policy Holder Name

First Last

Policy Holder Birthday

Policy Holder Social Security Number

Policy Holder Employer

Insurance Company Name

ID Number

Group Number

Insurance Company Phone Number

Do you plan to use flex spending or HSA funds?

Yes

Do you have dual coverage? (if yes, please fill out Secondary Insurance Information)

Yes

Secondary Insurance Information

Insured's Name

First Last

Birthday

Insured's Social Security Number

Policy Holder Employer

Insurance Company Name

ID Number

Group Number

Insurance Company Phone Number

Phone

This field is for validation purposes and should be left unchanged.

Patient Information

Responsible Party Information

Dental Insurance Information

Secondary Insurance Information

Ashland: (419) 289-1091

Wooster: (330) 345-3070

info@greggorthodontics.com

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