Patient Registration & Health History Form - Altoona Smiles 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your family name and first name in the designated fields. This ensures that your information is accurately recorded.
3. Fill in your date of birth, postcode/zip, street address, city, and contact numbers including private, business, and mobile. This information is crucial for identification and communication.
4. Provide your email address and profession along with employer details. This helps the clinic understand your background.
5. Indicate your health insurance status by selecting the appropriate options provided. This section is important for billing purposes.
6. Complete the invoice recipient section if applicable, ensuring all necessary details are filled out correctly.
7. Answer the health questions thoroughly. Mark any relevant diseases or conditions you may have to assist in providing tailored care.
8. Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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