• Skip to primary navigation
  • Skip to main content
  • Skip to footer
Fred Dahm Dentistry

Fred Dahm Dentistry

  • Home
  • OUR OFFICE
    • Renton Office
  • SERVICES
    • Cosmetic Dentistry
      • Smile Design with Porcelain Veneers
      • In-Office Laser Whitening
    • Implants
      • Single Implants
      • Replacing Multiple Teeth with Implants
      • Full Arch Full Mouth Rehabilitation with Implants (DIEM)
    • General Dentistry
      • Tooth-Colored (composite) Fillings
      • Porcelain Crowns and Bridges
      • Dental Implants
      • Extractions and Bone Grafts
      • Hygiene (cleaning) Services
  • MEET OUR TEAM
  • CONTACT / FORMS

Updated Medical History

Updated Medical History

Step 1 of 2 - Patient Information

50%
  • Fred R Dahm DDS Eunku Will Chung DDS MSD

  • Patient Information (Confidential)

  • Primary Dental Insurance Information

  • Secondary Dental Insurance Information

  • I certify that the above information is true to the best of my knowledge.If any of this information changes,I will provide that information to Fred Dahm DDS as soon as possible.I understand that failure to provide accurate insurance in a timely manner may result in being billed for the full fee for any services provided to me.

  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY
Save and Continue Later
  • Fred R Dahm DDS Eunku Will Chung DDS MSD

  • Patient Medical History

  • MM slash DD slash YYYY
  • Are you allergic to or have had reactions to the following?
  • Patient Dental History

  • MM slash DD slash YYYY
  • Have you ever experienced any of the following problems:

  • ***I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my children during the period of such dental care to third party payors and /or health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits for the payment of all services rendered on my behalf or dependents.***

  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, xlsx, xls, jpeg, doc, docx, txt, Max. file size: 50 MB.
    Save and Continue Later

    Footer

    info@freddahmdentistry.com

    RENTON OFFICE
    4004 NE 4th Street, Suite 106
    Renton WA 98056
    MAP IT

    2015 – 2022

    Copyright © 2023 Fred Dahm Dentistry . All rights reserved.