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Confidential Health History Form (English & Spanish)

June 21, 2019 2065

This form should be completed by each new patient or a new patient’s legal guardian. Additionally, it should be reviewed at least every six months and completed every two years by active patients. This form provides the practice a comprehensive report of a patient’s health history, including essential dental health history information. The form can be completed at the start of a patient’s appointment or prior to the appointment as long as the information is still current when the patient presents. Each health care provider should review the form in advance of treating the patient. Be certain to allow time in your schedule for this review.

Certain areas of medical information bear confidentiality restrictions:

  • The release of mental health information requires the written authorization of both the patient and the physician or other professional person in charge of the patient.
  • The release of drug and alcohol abuse records may only be released without patient authorization pursuant to a court order (not a subpoena).
  • The release of HIV/AIDS status requires the written authorization of the patient that specifically authorizes disclosure of that status.
  • Pregnancy of a minor cannot be released to the parent or guardian without the minor’s permission.