Patient Registration & Health History Form | Shelby Township & Macomb County, MI Dentists

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*

Today's Date*

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*

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

Social Security #

Date Employed

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

Social Security #

Date Employed

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*

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Phone

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