Patient Forms

ADA American Dental Association Health History Form

  • Date Format: DD slash MM slash YYYY

  • Date Format: MM slash DD slash YYYY

  • Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question)
  • If you answer yes to any of the 4 items above, please stop and call the receptionist (586) 294-0900

  • Dental Information

  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY

  • Medical Information

  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY

  • Allergy Information

    Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
  • Please mark the appropriate response to indicate if you have or have not had any of the following diseases or problems.
  • Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
  • 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.
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Hours of Operation:
Mon, Tues, Thurs: 9AM-5PM
Wed & Fri: 9AM-2PM
Saturday: 9AM-3PM
Sunday: Closed