What information does the Dental Clinic Medical Health History Form request?

It asks for the client's allergies, medications, height, weight, smoking and alcohol information, medical history, and other health concerns. It also includes consent for dental diagnosis and agreed treatment.

How do I submit the Dental Clinic Medical Health History Form?

The document does not give a submission address or method. Submit it to the county department named on the form; check the county website for current contact details.

When should a parent or guardian update this form?

The form says a parent or legal guardian should review and update it every year or sooner if any changes occur.

McLean County, IL · McLean County

No notary required

Dental Clinic Medical Health History Form

McLean County dental clinic clients or their guardians complete this form to report health history and consent to dental diagnosis and agreed treatment.

At a glance

Issued by: City of McLean County · McLean County, McLean County, Illinois
Notarization: Not required: file this form without a notary.
Official source: mcleancountyil.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

The form collects a dental client’s allergies, medications, health conditions, and other medical information, and includes consent for diagnostic procedures and mutually agreed treatment. The document also provides instructions for female clients who may be pregnant and explains when a minor needs parent or legal guardian permission or an advance proxy form. Parents or guardians are asked to review and update the form annually or sooner if information changes.

Who needs it

Clients receiving dental clinic care, or a parent or legal guardian completing the form for a minor, provide the requested health history and consent.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This form is signed and dated without a notary; it calls for written physician approval in certain pregnancy cases and an advance proxy form when applicable.

How to submit this form

1
Download the Form
Download the Medical Health History Form PDF.
2
Complete the Health History
Fill in the client's details and report allergies, medications, medical history, and other requested information.
3
Check Related Requirements
If applicable, arrange written physician approval for dental treatment during pregnancy or an advance proxy form for a minor.
4
Sign and Date
The parent, guardian, or client signs and dates the consent section as applicable.
5
Submit the Form
Submit it to the county department named on the form; check the county website for current contact details.

Frequently asked questions

What information does the Dental Clinic Medical Health History Form request?: It asks for the client's allergies, medications, height, weight, smoking and alcohol information, medical history, and other health concerns. It also includes consent for dental diagnosis and agreed treatment.
Do I need a notary for the Dental Clinic Medical Health History Form?: No. The form has signature and date lines but no notary block. It calls for written physician approval in certain pregnancy cases and an advance proxy form when applicable.
How do I submit the Dental Clinic Medical Health History Form?: The document does not give a submission address or method. Submit it to the county department named on the form; check the county website for current contact details.
When should a parent or guardian update this form?: The form says a parent or legal guardian should review and update it every year or sooner if any changes occur.

Need something notarized?

This Dental Clinic Medical Health History Form doesn’t need a notary, but Illinois residents can notarize other documents online with a commissioned online notary.