*= required
Insurance Company* Insurance Phone* Address* City* Address* Address*
Group No. (Plan or Policy No.)* Insured's ID# (Plan or Policy No.)*
Insured First Name (required) Insured Last Name (required)
Relation To Patient (required) Date Of Birth*
Insured's Social Security#* Insured's Employer Name
Is the insured a patient in our practice? YesNo
Insurance Company Insurance Phone Address City Address Address
Group No. (Plan or Policy No.) Insured's ID# (Plan or Policy No.)
Relation To Patient (required) Date Of Birth
Insured's Social Security# Insured's Employer Name
First Name Last Name Relationship To Patient Social Security# Phone Driver's License# DOB Address City State Employer Work Phone If patient is a minor, name of parent or legal guardian and relationship
Your Email *
Additional Information
I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I herby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including diagnosis and records of treatment or examination rendered, to my insurance company. I understand the above information is necessary to provide me with dental care in a safe efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask respective healthcare provider or agency that may release such information to you. I will notify the dentist of any changes of health or medication.
Your Email (required)
Today's Date (required)
Last Name (required)
First Name (required)
Middle Name
Address (required)
City (required)
State (required)
Zip (required)
Phone (required)
Occupation
SS# or Patient ID (required)
Emergency Contact (required)
Relationship (required)
Emergency Contact # (required)
Do you have any of the following diseases or problems:(Check DK if you Don’t Know the answer to the the question)
Active Tuberculosis
YesNoDK
Persistent cough (more than 3 weeks)
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and call the receptionist 1.248.594.9592
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Do you drink bottled or filtered water?
How often?
DailyWeeklyOccasionally
Date of your last exam
Date of your last Xrays
How do you feel about your smile? (required)
Are you now under the care of a physician?
Physician Name:
Phone:
Have you had complications? (required)
Are you in good health?
Has there been any changes in your general health with the past year?
If yes what condition(s) is being treated? (required)
Date of last physical exam:
Have you had a serious illness, operation or been hospitalized in the past 5 years?
(if yes) What was the illness or problem? (required)
Are you taking or have your recently taken any prescription or over the counter medicine(s)?
(if yes) please list all, including vitamins, natural or herbal preperations and/or dietary supplements: (required)
Do you wear contact lenses?
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Date treatment began:
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
(if so) Are you interested in stopping?
VerySomewhatNot Interested
Do you drink alcoholic beverages?
(if yes) please tell us about your drinking habits: (required)
Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbituarates, sedative, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex
Iodine
Hay fever/seasonal
Animals
food
Please tell us about your reaction(s) (required)
Please mark the appropriate response to indicate if you have or have not had any of the following diseases or problems.
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congentital heart defects
Mitral valve prolapse
Pacemaker
Rheumatic fever
rheumatic heart disease
Abnormal bleeding
Anemia
Hemophillia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systemic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/Radiation
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heart burn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorder
Sleep disorder
Do you smoke
Mental health disorders
Recurring infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in the neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination
Please explain any specific disorders, dates or procedures not listed above
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation:
Do you have any disease, condition, or problem not listed above that you think I should know about?
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Digital Signature: I confirm all information above to be valid and true.
