*= required

    Primary Carrier





















    YesNo

    Secondary Carrier





















    YesNo



    Person Financially Responsible for Account

    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 (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)
      YesNoDK
      Been exposed to anyone with tuberculosis
      YesNoDK

      If you answer yes to any of the 4 items above, please stop and call the receptionist 1.248.594.9592

      Dental Information

      Do your gums bleed when you brush or floss?
      YesNoDK
      Are your teeth sensitive to cold, hot, sweets or pressure?
      YesNoDK
      Is your mouth dry?
      YesNoDK
      Have you had any periodontal (gum) treatments?
      YesNoDK
      Have you ever had orthodontic (braces) treatment?
      YesNoDK
      Have you had any problems associated with previous dental treatment?
      YesNoDK
      Is your home water supply fluoridated?
      YesNoDK
      Are you currently experiencing dental pain or discomfort?
      YesNoDK
      Do you have earaches or neck pains?
      YesNoDK
      Do you have earaches or neck pains?
      YesNoDK
      Do you have any clicking, popping or discomfort in the jaw?
      YesNoDK
      Do you brux or grind your teeth?
      YesNoDK
      Do you have sores or ulcers in your mouth?
      YesNoDK
      Do you wear dentures or partials?
      YesNoDK
      Do you participate in active recreational activities?
      YesNoDK
      Have you ever had a serious injury to your head or mouth?
      YesNoDK
      Do you drink bottled or filtered water?
      YesNoDK
      How often?
      DailyWeeklyOccasionally
      Date of your last exam
      Date of your last Xrays
      How do you feel about your smile? (required)

      Medical Information

      Are you now under the care of a physician?
      YesNoDK
      Physician Name:
      Phone:




      Have you had complications? (required)
      Are you in good health?
      YesNoDK
      Has there been any changes in your general health with the past year?
      YesNoDK
      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?
      YesNoDK
      (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)?
      YesNoDK
      (if yes) please list all, including vitamins, natural or herbal preperations and/or dietary supplements: (required)
      Do you wear contact lenses?
      YesNoDK
      Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
      YesNoDK
      Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?
      YesNoDK
      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?
      YesNoDK
      Date treatment began:
      Do you use controlled substances (drugs)?
      YesNoDK
      Do you use tobacco (smoking, snuff, chew, bidis)?
      YesNoDK
      (if so) Are you interested in stopping?
      VerySomewhatNot Interested
      Do you drink alcoholic beverages?
      YesNoDK
      (if yes) please tell us about your drinking habits: (required)

      Allergy Information

      Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

      Local anesthetics
      YesNoDK
      Aspirin
      YesNoDK
      Penicillin or other antibiotics
      YesNoDK
      Barbituarates, sedative, or sleeping pills
      YesNoDK
      Sulfa drugs
      YesNoDK
      Codeine or other narcotics
      YesNoDK
      Metals
      YesNoDK
      Latex
      YesNoDK
      Iodine
      YesNoDK
      Hay fever/seasonal
      YesNoDK
      Animals
      YesNoDK
      food
      YesNoDK
      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
      YesNoDK
      Previous infective endocarditis
      YesNoDK
      Damaged valves in transplanted heart
      YesNoDK
      Congenital heart disease
      YesNoDK


      Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.


      Cardiovascular disease
      YesNoDK
      Angina
      YesNoDK
      Arteriosclerosis
      YesNoDK
      Congestive heart failure
      YesNoDK
      Damaged heart valves
      YesNoDK
      Heart attack
      YesNoDK
      Heart murmur
      YesNoDK
      Low blood pressure
      YesNoDK
      High blood pressure
      YesNoDK
      Other congentital heart defects
      YesNoDK
      Mitral valve prolapse
      YesNoDK
      Pacemaker
      YesNoDK
      Rheumatic fever
      YesNoDK
      rheumatic heart disease
      YesNoDK
      Abnormal bleeding
      YesNoDK
      Anemia
      YesNoDK
      Hemophillia
      YesNoDK
      AIDS or HIV infection
      YesNoDK
      Arthritis
      YesNoDK
      Autoimmune disease
      YesNoDK
      Rheumatoid arthritis
      YesNoDK
      Systemic lupus erythematosus
      YesNoDK
      Asthma
      YesNoDK
      Bronchitis
      YesNoDK
      Emphysema
      YesNoDK
      Sinus trouble
      YesNoDK
      Tuberculosis
      YesNoDK
      Cancer/Chemotherapy/Radiation
      YesNoDK
      Chest pain upon exertion
      YesNoDK
      Chronic pain
      YesNoDK
      Diabetes Type I or II
      YesNoDK
      Eating disorder
      YesNoDK
      Malnutrition
      YesNoDK
      Gastrointestinal disease
      YesNoDK
      G.E. Reflux/persistent heart burn
      YesNoDK
      Ulcers
      YesNoDK
      Thyroid problems
      YesNoDK
      Stroke
      YesNoDK
      Glaucoma
      YesNoDK
      Hepatitis, jaundice or liver disease
      YesNoDK
      Epilepsy
      YesNoDK
      Fainting spells or seizures
      YesNoDK
      Neurological disorder
      YesNoDK
      Sleep disorder
      YesNoDK
      Do you smoke
      YesNoDK
      Mental health disorders
      YesNoDK
      Recurring infections
      YesNoDK
      Kidney problems
      YesNoDK
      Night sweats
      YesNoDK
      Osteoporosis
      YesNoDK
      Persistent swollen glands in the neck
      YesNoDK
      Severe headaches/migraines
      YesNoDK
      Severe or rapid weight loss
      YesNoDK
      Sexually transmitted disease
      YesNoDK
      Excessive urination
      YesNoDK
      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?
      YesNoDK
      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?
      YesNoDK



      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: