New Patient Paperwork

PLEASE FILL OUT ALL REQUIRED FIELDS

"*" indicates required fields

Step 1 of 5

New Patient Health History

Patient Information

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Gender:*
Who is accompanying the child today
Relation:*
Is your child a ward of the state?*

Parent Information

Who does the patient live with?*
Guardian (I)
Gender:*
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Marital Status:*
Guardian (II)
Gender:
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Marital Status:

Dental Insurance Information

Primary Coverage
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Secondary Coverage
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Referral Information

Select any that apply:*

Dental History

Dental Concerns

What is the pimary reason for today's visit?*
Has your child ever been to the dentist?*
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Do you think your child will react well to treatment?*

Dental Habits

Does your child currently... (check all that apply):*

Hygiene Routine

Check all that apply:*

Medical History

Are immunizations current?*
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Is your child followed by a specialist?*
Please check if your child has been treated for any of the following:*
ALLERGIES:*

Consent for Dental Treatment

I affirm that the above information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the patient's medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I understand that PD of Michigan PLLC may use and disclose pertinent health information and dental records to coordinate and manage dental care and related services to one or more health care providers or other dental specialists. I authorize the release of all information necessary to secure benefits such as obtaining reimbursement for services, confirming coverage, bill or collection activities and utilization review. I understand that I am responsible for the full balance of the account regardless of my dental benefits and directly assign Pediatric Dentistry of Michigan all insurance payments otherwise payable to me. In case of default, I agree to pay all reasonable costs and fees associated with the collection of the account balance, including by not limited to, third party collection fees, court filing fees and attorney fees. I affirm that my signature represents my agreement to all of the terms mentioned above.

Clear Signature
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