Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

Medical History Update

Patient's Name
Date of birth
Phone
Email

AN X-RAY(S) IS NECESSARY TODAY TO ESTABLISH A COMPLETE DIAGNOSIS.

I have reviewed the attached Medical History. My (or patients) health and medications have changed as follows
Address or Phone # change:
Dental Insurance:

if Yes, Please provide our office with a copy of insurance card or information

Reviewed by
Medical History: please make a check mark whether you now have or have ever been treated for:

Patient's Signature or (Parent's if minor)

Use your mouse cursor or the tip of your finger to sign below

Date: