Free standard medical history acknowledgment — professional wording your business can adapt in minutes. Available in English, Español and 中文. Swap the [bracketed] parts, or let KwickPhone fill in your business name automatically.
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Medical History Statement
I confirm the medical and dental history I provided to [Business Name] is complete and accurate, including all medications, supplements, allergies (drugs, latex, anesthetics), heart conditions, diabetes, bleeding disorders, pregnancy and prior reactions to dental care. I will tell the office about any change in my health or medications before future visits. I understand withholding health information can make treatment unsafe.
Declaración de Historial Médico
Confirmo que el historial médico y dental que proporcioné a [Nombre del Negocio] es completo y preciso, incluidos todos los medicamentos, suplementos, alergias (medicamentos, látex, anestésicos), condiciones cardíacas, diabetes, trastornos de coagulación, embarazo y reacciones previas a tratamientos dentales. Informaré al consultorio cualquier cambio en mi salud o medicamentos antes de futuras visitas. Entiendo que ocultar información de salud puede hacer inseguro el tratamiento.
⚖️ These templates are general starting points, not legal advice. Rules differ by state and by business — have your attorney review your final wording before you use it.
State-by-state differences
TX — Texas: informed-consent disclosures follow the Texas Medical Disclosure Panel lists; document consent for procedures on List A in writing.
CA — California: patients may request records within 5 working days (inspection); CMIA privacy rules apply on top of federal privacy requirements.
FL — Florida: dental records must be kept at least 4 years (Board rule); patient-abandonment rules require 30 days' coverage after ending care.
NY — New York: patient records must be retained 6 years (adults) or until a minor turns 22; surprise-bill disclosures apply to out-of-network care.
IL — Illinois: dental records generally retained 10 years; patients get copies within 30 days of a written request (fees capped by statute).
NJ — New Jersey: patient records kept at least 7 years from the last entry; provide copies within 30 days of request.
GA — Georgia: retain records 10 years from the last entry (minors longer); Board of Dentistry rules govern transfers when a practice closes.
CO — Colorado: dental board rules require records for 7 years after the last treatment (or age 25 for minors, whichever is later).
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