Patient Registration & Health History Form

Contact our Shelby Township dental office today to learn more about our dentists or to request an appointment.

Patient Information (Confidential):

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all of your dental healthcare needs, please fill out this form completely, If you have questions or need assistance, please contact us – we will be happy to help!
Name*
Birthdate*
MM slash DD slash YYYY
Today's Date*
MM slash DD slash YYYY
Address*
City*
Zip Code*
Email*
Home Phone
Cell Phone*
Social Security #*
Driver's License #*
Check Appropriate Boxes*
- Minor
- Single
- Married
Patient Employer*
Work Phone
Spouse or Parent/Guardian's Name
Work Phone
Spouse or Parent/Guardian's Employer
City
Whom May We Thank for Referring You?
Person to Contact in Case of an Emergency*
Phone*
Is the Responsible Party Different from Above?*
- Same as Above
- Different from Above
Name of Person Responsible for the Account*
Relationship to Patient*
Address*
Email*
Cell Phone*
Home Phone
Driver's License #*
Birthdate*
MM slash DD slash YYYY
Social Security #*
For your convenience, we offer the following methods of payment. Please check the option you prefer:
Cash/Check:
- Cash
- Personal Check
Credit Card:
- VISA
- MasterCard
- Care Credit
- Amex
Insurance Information
Name of Insured
Relationship to Patient
Birthdate
MM slash DD slash YYYY
Social Security #
Date Employed
MM slash DD slash YYYY
Name of Employer
Work Phone
Insurance Company
Group #
Policy ID #
Do You Have Additional Insurance? (If yes, please complete the following)*
- Yes
- No
Name of Insured
Relationship to Patient
Birthdate
MM slash DD slash YYYY
Social Security #
Date Employed
MM slash DD slash YYYY
Name of Employer
Work Phone
Insurance Company
Group #
Policy ID #
Patient Medical History
Patient's Name*
Although dental personnel primarily treat the area in the and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?*
- Yes
- No
- N/A
If yes, explain:
Have you ever been hospitalized or had a major operation?*
- Yes
- No
- N/A
If yes, explain:
Have you ever had a serious head or neck injury?*
- Yes
- No
- N/A
If yes, explain:
Are you taking any medication, pills, or prescription drugs?*
- Yes
- No
- N/A
If yes, explain:
Do you take, or have you taken, Phen-Fen or Redux?*
- Yes
- No
- N/A
If yes, explain:
Are you on a special diet?*
- Yes
- No
- N/A
If yes, explain:
Do you use tobacco?*
- Yes
- No
- N/A
If yes, explain:
Do you use controlled substances?*
- Yes
- No
- N/A
If yes, explain:
Women Only: Are you...
Pregnant or trying to get pregnant?
- Yes
- No
Nursing?
- Yes
- No
Taking oral contraceptives?
- Yes
- No
Are you allergic to any of the following?
Aspirin*
- Yes
- No
Penicillin*
- Yes
- No
Codeine*
- Yes
- No
Acrylic*
- Yes
- No
Metal*
- Yes
- No
Latex*
- Yes
- No
Local Anesthetics*
- Yes
- No
Other*
- Yes
- No
If other, please specify
Do you have, or have you ever had, any of the following?
AIDS/HIV Positive*
- Yes
- No
Alzheimer's Disease*
- Yes
- No
Anaphylaxis*
- Yes
- No
Anemia*
- Yes
- No
Angina*
- Yes
- No
Arthritis/Gout*
- Yes
- No
Artificial Heart Valve †*
- Yes
- No
Artificial Joint †*
- Yes
- No
Asthma*
- Yes
- No
Blood Disease*
- Yes
- No
Blood Transfusion*
- Yes
- No
Breathing Problems*
- Yes
- No
Bruise Easily*
- Yes
- No
Cancer*
- Yes
- No
Chemotherapy*
- Yes
- No
Chest Pains*
- Yes
- No
Cold Sores/Fever Blisters*
- Yes
- No
Congenital Heart Disorder*
- Yes
- No
Convulsions*
- Yes
- No
Cortisone Medicine*
- Yes
- No
Diabetes*
- Yes
- No
Drug Addiction*
- Yes
- No
Easily Winded*
- Yes
- No
Emphysema*
- Yes
- No
Epilepsy or Seizures*
- Yes
- No
Excessive Bleeding*
- Yes
- No
Excessive Thirst*
- Yes
- No
Fainting Spells/Dizziness*
- Yes
- No
Frequent Cough*
- Yes
- No
Frequent Diarrhea*
- Yes
- No
Frequent Headaches*
- Yes
- No
Genital Herpes*
- Yes
- No
Glaucoma*
- Yes
- No
Hay Fever*
- Yes
- No
Heart Attack/Failure*
- Yes
- No
Heart Murmur †*
- Yes
- No
Heart Pace Maker †*
- Yes
- No
Heart Trouble/Disease*
- Yes
- No
Hemophilia*
- Yes
- No
Hepatitis A*
- Yes
- No
Hepatitis B or C*
- Yes
- No
Herpes*
- Yes
- No
High Blood Pressure*
- Yes
- No
Hivesor Rash*
- Yes
- No
Hypoglycemia*
- Yes
- No
Irregular Heartbeat*
- Yes
- No
Kidney Problems*
- Yes
- No
Leukemia*
- Yes
- No
Liver Disease*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Lung Disease*
- Yes
- No
Mitral Valve Prolapse †*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Parathyroid Disease*
- Yes
- No
Psychiatric Care*
- Yes
- No
Radiation Treatments*
- Yes
- No
Recent Weight Loss*
- Yes
- No
Renal Dialysis*
- Yes
- No
Rheumatic Fever †*
- Yes
- No
Rheumatism*
- Yes
- No
Scarlet Fever*
- Yes
- No
Shingles*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Sinus Trouble*
- Yes
- No
Spina Bifida*
- Yes
- No
Stomach/Intestinal Disease*
- Yes
- No
Stroke*
- Yes
- No
Swelling of Limbs*
- Yes
- No
Thyroid Disease*
- Yes
- No
Tonsilitis*
- Yes
- No
Tuberculosis*
- Yes
- No
Tumors or Growths*
- Yes
- No
Ulcers*
- Yes
- No
Venereal Disease*
- Yes
- No
Yellow Jaundice*
- Yes
- No
† Condition may require medication.
Have you ever had any serious illness not listed above?*
- Yes
- No
- N/A
If yes, please explain:
Comments/Concerns
Signature

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 the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services.I agree to be responsible for payment of all services rendered on my behalf or my dependents. I also authorize to have photographs of my face, jaws and teeth taken. I understand that these items will be used as a record of my care, and may be used for educational purposes. I further understand that if these items are used in any publication or as a part of a demon stration, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.
Signature of Patient/Legal Guardian*
Printed Name*
Date*
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Patient Registration & Health History Form

Patient Information (Confidential):

For your convenience, we offer the following methods of payment. Please check the option you prefer:

Insurance Information

Patient Medical History

Women Only: Are you...

Are you allergic to any of the following?

Do you have, or have you ever had, any of the following?

Signature