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

  •  
  • 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
      • DENTAL 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
  • SECONDARY 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

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Are you under a physician's care now?
  • YesNo
  • Physician Name:
  • Physician Phone #:
  • Have you ever had a serious head or neck injury?
  • YesNo
  • If yes
  • Have you ever been hospitalized or had a major operation?
  • YesNo
  • If yes
  • Are you taking any medications, pills, or drugs?
  • YesNo
  • If yes
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  • YesNo
  • If yes
  • Are you on a special diet?
  • YesNo
  • If yes
  • Do you use tobacco?
  • YesNo
  • If yes
  • Do you use controlled substances?
  • YesNo
  • If yes
  • Do you take or need antibiotics before dental procedures?
  • YesNo
  • If yes


  • Women: Are you...
  • Pregnant/Trying to get pregnant?
  • Nursing?
  • Taking oral contraceptives?
  • Are you allergic to any of the following?
    • Aspirin
    • YesNo
    • Metal
    • YesNo
    • Penicillin
    • YesNo
    • Sulfa Drugs
    • YesNo
    • Codeine
    • YesNo
    • Local Anesthetics
    • YesNo
    • Acrylic
    • YesNo
    • Latex
    • YesNo
  • Any other allergies?
  • YesNo
  • If Yes


  • Do you have or have ever had:
    • Cancer
    • YesNo
    • HIV/AIDS
    • YesNo
    • Rheumatic/Scarlet Fever
    • YesNo
    • Radiation Treatments
    • YesNo
    • Hives or Rash
    • YesNo
    • Tumors or Growths
    • YesNo
    • Fatigued/Tired
    • YesNo
    • Joint Replacement
    • YesNo
    • Recent Trauma/Injury
    • YesNo
    • Shingles
    • YesNo
    • General Weakness
    • YesNo
    • Liver Problems
    • YesNo
    • Recent Weight Loss
    • YesNo
    • Frequent Headaches
    • YesNo
    • Chemotherapy
    • YesNo
    • Excessive Thirst
    • YesNo
    • Swelling of Limbs
    • YesNo
  • Cordiovascular System
    • Artificial Heart Valve
    • YesNo
    • High Blood Pressure
    • YesNo
    • Tachycardia
    • YesNo
    • Chest Pain or Angina
    • YesNo
    • Low Blood Pressure
    • YesNo
    • Congenital Heart Defect
    • YesNo
    • Heart Attack
    • YesNo
    • Mitral Valve Prolapse
    • YesNo
    • Congestive Heart Failure
    • YesNo
    • Heart Murmur
    • YesNo
    • Pacemaker
    • YesNo
    • High Cholesterol
    • YesNo
  • Endocrine
    • Diabetes
    • YesNo
    • Thyroid Problems
    • YesNo
    • Hormonal Change
    • YesNo
    • Hypoglycemia
    • YesNo
  • Eyes, Ears, Nose, Throat
    • Change in Hearing
    • YesNo
    • Glaucoma
    • YesNo
    • Sinus Problems
    • YesNo
    • Change in Vision
    • YesNo
    • Hay Fever
    • YesNo
    • Tonsillectomy
    • YesNo
    • Difficulty Swallowing
    • YesNo
    • Nasal Obstruction
    • YesNo
    • Ringing in Ears(Tinnitis)
    • YesNo
    • Ear Pain
    • YesNo
    • Nose Bleeding
    • YesNo
  • Gastrointestinal
    • Acid Reflux
    • YesNo
    • Stomach/Intestinal Disease
    • YesNo
    • GERD
    • YesNo
    • Frequent Diarrhea
    • YesNo
    • Soft of Special Diet
    • YesNo
    • Ulcers
    • YesNo

  • Comments


  • Genitourinary
    • Frequent Urination
    • YesNo
    • Renal Dialysis
    • YesNo
    • Kidney Problems
    • YesNo
    • Venereal Disease
    • YesNo
    • Nocturia(Bed)
    • YesNo
    • Genital Herpes
    • YesNo
  • Hematological
    • Bleeding Problems
    • YesNo
    • Anemia
    • YesNo
    • Leukemia
    • YesNo
    • Anemia
    • YesNo
    • Blood Disease
    • YesNo
    • Blood Transfusion
    • YesNo
    • Hemophilia
    • YesNo
    • Bruise Easily
    • YesNo
  • Musculoskeletal
    • Back Pain
    • YesNo
    • Osteoporosis
    • YesNo
    • Fibromyalgia
    • YesNo
    • Spina Bifida
    • YesNo
    • Arthritis/Gout
    • YesNo
    • Muscle Weakness
    • YesNo
    • Rheumatism
    • YesNo
  • Neurological
    • Alzheimer's Disease
    • YesNo
    • Epilepsy or Seizures
    • YesNo
    • Tremor
    • YesNo
    • Dizziness/Fainting
    • YesNo
    • Stroke
    • YesNo
    • Parkinson's Disease
    • YesNo
    • Memory Loss
    • YesNo
    • Tingling/Numbness
    • YesNo
    • Convulsions
    • YesNo
    • Multiple Sderosis
    • YesNo
    • Trigeminal Neuralgia
    • YesNo
  • Oral
    • Bleeding Gums
    • YesNo
    • Jaw Joint Pain
    • YesNo
    • Teeth denching/grinding
    • YesNo
    • Canker Sores
    • YesNo
    • Dry Mouth
    • YesNo
    • Difficulty Chewing
    • YesNo
    • Tooth Pain
    • YesNo
    • Cold Sores/Fever Blisters
    • YesNo
    • Jaw Joint Problems
    • YesNo
    • Difficulty Chewing
    • YesNo
    • Orthodontics / Invisalign
    • YesNo
    • Wisdom Teeth Extraction
    • YesNo
    • Jaw Joint Clicking
    • YesNo
    • Periodontal Disease
    • YesNo
    • Have Removable Teeth
    • YesNo
  • Psychiatric
    • ADD/ADHD
    • YesNo
    • Eating Disorders
    • YesNo
    • Anxiety
    • YesNo
    • Excessive Stress
    • YesNo
    • Chemical Dependency
    • YesNo
    • Memory Problems
    • YesNo
    • Depression
    • YesNo
    • Psychiatric Care
    • YesNo
  • Respiratory
    • Asthma
    • YesNo
    • Emphysema
    • YesNo
    • Lung Disease
    • YesNo
    • Bronchitis
    • YesNo
    • Easily Winded/Dyspnea
    • YesNo
    • Tuberculosis
    • YesNo
    • Breathing Problems
    • YesNo
    • Pneumonia
    • YesNo
    • Congestion
    • YesNo
    • Frequent Cough
    • YesNo
  • Sleep
    • Daytime Sleepiness
    • YesNo
    • Snoring
    • YesNo
    • Morning Headaches
    • YesNo
    • Obstructive Sleep Apnea
    • YesNo
    • Do you use a CPAP
    • YesNo
  • Have you ever had any serious illness not listed above?
  • YesNo
  • If yes

  • Comments:

  • 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 athorough 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 anesthetic agents embodies certain risks 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 understant 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 office will not bill a non-costodial parent. I understand that I am responsibile for any portion of fees for service 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 responsibile 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 aompany with information required for a claim, to assign benefits payable to him, and to handle any necessary claim appeal(s) on my behalf.

  • Signature of Patient, Parent or Guardian:
  • Date:

  • Notice of Privacy Practices(below)
  • NOTICE OF PRIVACY PRACTICES: Patient privacy is important to out practice. We are required by law to maintain the privacy of Protected Health Information("PHI") 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 practice's policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable) and my other medical providers.
  • Patient Signature
  • Date:

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