welcome

Keith W.kelley, DDS   •   1913 W. South Blvd.   •   Troy,Michigan 48098   •   (248) 828-3185

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  • PATIENT INFORMATION
  •  
  • Name
  • Dr.Mr.Mrs.Ms.Rev.
  • other:
  • Address
  • Driver's Lic #
  • MaleFemale
  • City
  • State
  • Zip
  • Hm#
  • Employer
  • Wk#
  • Are you:
  • MinorMarriedSingleDivorcesWidowedSeparated
  • Cell
  • DOB
  • SSN #
  • E-mail
  • Spouse Name:
  • Spouse's Occupation
  • Workphone
  • Ext
  • Is Patient a full time student?
  • NO
  • YES
  • Name of school:
    • RESPONSIBLE PARTY (if different than patient)
      • Name
      • Address
      • City
      • State
      • Zip
      • Hm#
      • Wk#
      • DOB
      • SSN#
      • Relationship
      • INSURANCE INFORMATION
      • MEDICAL INSURANCE:
    • YOUR PREFERENCES
      • Do you prefer appoinment reminder by:
      • EmailPhoneText
      • Do you prefer to recive calls from our office at:
      • HomeWorkCell
      • How did you hear about our office?
      • How do you wish to be adderessed by our team members?
  • Subscriber's Name
  • Relationship to patient
  • DOB
  • Subscriber's ID#
  • Insurance Company
  • Policy #
  • Group
  • SUPPLEMENTAL INSURANCE (DENTAL):
  • Insured Name
  • Relationship to patient
  • Address
  • City
  • State
  • Zip
  • DOB
  • ID #
  • Employer
  • Insurance Company
  • Group #
  • DO YOU HAVE ADDITIONAL DENTAL INSURANCE?
  • YESNO
  • If yes, please complete the following:
  • Insured Name
  • Relationship to patient
  • Address
  • City
  • State
  • Zip
  • DOB
  • ID #
  • Employer
  • Insurance Company
  • Group #

MEDICAL HISTORY AND CONSENT
Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health
conditions or problems that you may have or had, or medications that you may be taking, could have an important
interrelationship with the treatment you will receive. Thank you for answering the following questions.
    • Allergies
      • Yes No
        Acrylics
        Anaphylaxis
        Latex
        Local Anesthetics
        Penicillin
        Metal
        Sulpha
        Other
      • List other known allergies
      • Cardiovascular
      • Yes No
        Artificial Heart Valve
        Coronary Artery Disease
        Chest Pain or Angina
        Congestive Heart Failure
        Heart Attack
        Heart Murmur
        High Blood Pressure
        High Cholesterol
        Irregular Heart Beat
        Low Blood Pressure
        Mitral Valve Prolapse
        Pacemaker
        Tachycardia
      • Endocrine
      • Yes No
        Diabetes
        Gout
        Hormonal Change
        Thyroid problems
      • Eyes, Ears, Nose and Throat
      • Yes No
        Change in Hearing
        Change in Vision
        Dysphagia
        Ear Pain
        Glaucoma
        Hay Fever
        Nasal Obstruction
        Nose Bleeding
        Sinus Problems
        Tonsillectomy
        Tinnitus (Ringing)
    • Gastrointestinal
      • Yes No
        Acid Reflux
        GERD
        Soft or Special Diet
        Ulcers
      • Genitourinary
      • Yes No
        Frequent Urination
        Kidney disease
        Nocturia
      • General
      • Current weight:lbs
      • Height:ftin
      • Yes No
        Cancer
        Fatigue/Tired
        General Weakness
        Headaches
        HIV/AIDS
        Knee/hip replacement
        Liver problems
        Recent Trauma or Injury
        Rheumatic Fever
        Radiation Treatment
        Weight Change
      • Hematological
      • Yes No
        Bleeding problems
        Hepatitis
      • Oral
      • Yes No
        Bleeding gums
        Dry mouth
        Jaw problems (TMJ)?
        Clicking?
        Pain?
        Difficulty swallowing?
        Difficulty chewing?
        Orthodontics/Invisalign
        Periodontal Disease
        Teeth clenching
        Teeth grinding
        Tooth pain
        Wisdom teeth extraction
        Do you wear removable teeth?
        Do you take or need antibiotics before dental procedures?
      • Musculoskeletal
      • Yes No
        Back Pain
        Fibromyalgia
        Joint Pain
    • Neurological
      • Alzheimer's Disease
        Dizziness
        Fainting
        Memory Loss
        Multiple Sclerosis (MS)
        Muscle Weakness
        Seizures
        Stroke
        Tingling/Numbness
        Trigeminal Neuralgia
        Tremor
      • Psychiatric
      • Yes No
        ADD/ADHD
        Anxiety
        Chemical Dependency Depression
        Eating disorders
        Excessive Stress
        Memory problems
      • Respiratory
      • Yes No
        Asthma
        Bronchitis
        Breathing problems
        Chest Pressure
        Congestion
        Dyspnea(shortness of breath)
        Emphysema
        Orthopnea(shortness of breath lying down)
        Pneumonia
        Pulmonary Embolism
        Tuberculosis
      • Sleep
      • Yes No
        Daytime Sleepiness
        Morning headaches
        Obstructive Sleep Apnea
        Do you use a CPAP?
      • How often?
      • Has anyone told you that you snore?
      • Social History
      • Yes No
        Do you smoke?
      • packs a day
      • Do you use smokeless tobacco?
      • Do you consume alcoholic beverages?
      • Drinks per day/week/month
      • Do you use recreational drugs?


MEDICAL HISTORY and CONSENT
    • List any medications you are taking:
      • Medication
      • Dosage/Freq.
      • Prescriber
      • Reason
      • 1.
      • 2.
      • 3.
      • 4.
      • 5.
    • List any surgeries or hospitalizations you have had:
      • Date(year)
      • Surgery
      • Surgeon
      • Reason
  • List and detail any medical condition or history not listed above:
  • Primary Physician's Name:
  • Physician's phone #:
  • Are you under the care of other physicians? If so, please list:
  • Physician
  • Phone #
  • Reason
  • GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Keith W. Kelley, DDS to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient's dental condition and needs. I authorize Keith W. Kelley, DDS to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Keith W. Kelley, DDS choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Keith W. Kelley, DDS. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status.
    FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. This ofEce will not bill anon-custodial parent. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I further consent to and agree to pay a 7% annual finance charge that will be applied to any balance over 30 days; returned checks will incur a $25.00 fee. I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Keith W. Kelley, DDS and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.



  • Consent (adult):
  • Name of Patient
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  • Date:
  • Consent (for a minor child):
  • Name of Parent/Guardian
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  • Date:


    • Notice of Privacy Practices (below)
      Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information ("PM") and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging receiving notice of our practices' policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable) and my other medical providers.

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    • Date:




Keith W. Kelley D.D.S.

1913 W. South Blvd, Troy, MI 48098
(248) 828-3185
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
  • SECTION A: PATIENT GIVING CONSENT
  • Name
  • ADDRESS:
  • TELEPHONE
  • E-MAIL:
  • SOCIAL SECURITY #
  • PATIENT ID#
  • SECTION B: TO THE PATIENBT - PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
  • Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.


  • Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the use and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read carefully and completely before signing this Consent.
  • We reserve the right to change our privacy practice as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
  • You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
    Contact Person: DeAnna LaMothe
    Telephone: 248-828-3185 Fax: 248-828-0197
    Address: 1913 W. South Blvd., Troy, MI 48098
    Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand the revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
  • I, , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and healthcare operations.
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  • Date:
  • If this Consent is signed by a personal representative of behalf of the patient, complete the following:
  • Personal Representative's Name:
  • Relationship to Patient:
  • YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
    Include completed Consent in the patient's chart.
  • REVOCATION OF CONSENT
  • I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.
  • I understand that revocation of my consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.
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  • Date:

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