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Office Address

4550 Investment Drive, Suite 290 Troy, Michigan 48098

Call Now

248-267-9700

Call Now

248-267-9700

New Patient Form

You may fill out 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.

Please do not print this page and fill it out.

If you wish to print a hard copy and fill it out manually, please click here to download the blank form (PDF). It can be printed, filled out manually and brought into our office on the day of your appointment.

    Registration Form

    Please complete all required fields.



     
    Please complete this section if Patient is a minor.

     
    Insurance

     

    Health History Questionnaire


     
    Current Medications:

     
    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.

      Please type “None” if you do not wish to allow anyone to receive information regarding your medical condition.



    Contact us

    Conveniently located in Troy Michigan.

    • Phone 248.267.9700
    • Hours Monday – Friday 8:30am – 4:30pm
    • Address 4550 Investment Drive, Suite 290
      Troy, Michigan 48098