(248) 267-9700

New Patient Form

You may use the form on this page to generate a "New Patient Information Form" which will be sent to our office. You'll also be able to conveniently download a copy for yourself.

If you prefer, click here to download the blank form (PDF) and fill it out manually.

Registration Form




Please complete this section if Patient is a minor.




Insurance


Health History Questionnaire


Are you allergic or have you reacted adversely to any of the following medications? (If yes, please check):
* Latex: NoYes
Are you allergic to any of the following? (check all that apply)

Penicillin

Tetracycline

Erythromycin

Other Antibiotic

Aspirin

Codeine

Local Anesthetic

* Any medication allergy: NoYes


Please check any of the following which you have had or have now.

Heart Failure
Heart Disease or Attack
Anemia
High Blood Pressure
Emphysema
Mitral Valve Prolapse
TB
Congenital Heart Lesions
Artificial Heart Valve
Heart Pacemaker
Heart Surgery
Heart Murmur
Diabetes
Kidney Disease
Ulcers
Arthritis
Cough
Cold Sores
Asthma
Hay Fever
Allergies or Hives
Venereal Disease
Stroke
Blood Transfusion
Bruise Easily
Thyroid Disease
Drug Addiction
Rheumatism
Fever Blisters
Glaucoma
Sinus Problems
Aids HIV
X-ray Radiation or Cobalt
Hepatitis or Liver Disease
Angina Pectoris
Sickle Cell Disease
Scarlet Fever
Hemophilia
Rheumatic Fever
Cortisone Medicine
Epilipsy or Siezures
Fainting or Dizzy Spells
Chemotherapy Cancer or Leukemia

I certify that the above information is true.

Acknowledgement of the Notice of Privacy Practices



Please complete this section if Patient is a minor.


Please list name of person(s) that you would allow our office to give information to regarding your medical condition.