Health History Update - The Hills Family Dentistry

The Hills Family Dentistry

Health History Update Portal

1. Verify Identity

2. Review Records

3. Submit Updates

🔐

Secure Patient Verification

Enter your information exactly as it appears in our records

First Name *

Last Name *

Date of Birth *

Email Address * Must match the email from your original intake

Review and Update Your Information

🔄 Modified fields are highlighted 📝 Click edit to modify ✓ All changes are tracked

👤 Personal Information

First Name

Last Name

Date of Birth

Gender

Phone

Street Address

City

State

ZIP Code

🚨 Emergency Contact

Contact Name

Relationship

Contact Phone

🏥 Medical History

Primary Physician

Physician Phone

Current Medications

Known Allergies

Medical Conditions

🦷 Dental History

Last Dental Visit

Reason for Visit

Dental Concerns

📋 Insurance Information

Insurance Company

Member ID

Group Number

Employer

💊 Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

✍️ Patient Verification & Signature

I certify that the information provided above is accurate and complete.

Signed on: 09/14/2025

✓

Health History Successfully Updated

Your updated records have been securely stored.