welcome

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 #
  • Male Female
  • City
  • State
  • Zip
  • Hm#
  • Employer
  • Wk#
  • Are you:
  • Minor Married Single Divorces Widowed Separated
  • 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:
      • Email Phone Text
      • Do you prefer to recive calls from our office at:
      • Home Work Cell
      • 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?
  • YES NO
  • 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?
  • Yes No
  • Physician Name:
  • Physician Phone #:
  • Have you ever had a serious head or neck injury?
  • Yes No
  • If yes
  • Have you ever been hospitalized or had a major operation?
  • Yes No
  • If yes
  • Are you taking any medications, pills, or drugs?
  • Yes No
  • If yes
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  • Yes No
  • If yes
  • Are you on a special diet?
  • Yes No
  • If yes
  • Do you use tobacco?
  • Yes No
  • If yes
  • Do you use controlled substances?
  • Yes No
  • If yes
  • Do you take or need antibiotics before dental procedures?
  • Yes No
  • If yes


  • Women: Are you...
  • Pregnant/Trying to get pregnant?
  • Nursing?
  • Taking oral contraceptives?
  • Are you allergic to any of the following?
    • Aspirin
    • Yes No
    • Metal
    • Yes No
    • Penicillin
    • Yes No
    • Sulfa Drugs
    • Yes No
    • Codeine
    • Yes No
    • Local Anesthetics
    • Yes No
    • Acrylic
    • Yes No
    • Latex
    • Yes No
  • Any other allergies?
  • Yes No
  • If Yes


  • Do you have or have ever had:
    • Cancer
    • Yes No
    • HIV/AIDS
    • Yes No
    • Rheumatic/Scarlet Fever
    • Yes No
    • Radiation Treatments
    • Yes No
    • Hives or Rash
    • Yes No
    • Tumors or Growths
    • Yes No
    • Fatigued/Tired
    • Yes No
    • Joint Replacement
    • Yes No
    • Recent Trauma/Injury
    • Yes No
    • Shingles
    • Yes No
    • General Weakness
    • Yes No
    • Liver Problems
    • Yes No
    • Recent Weight Loss
    • Yes No
    • Frequent Headaches
    • Yes No
    • Chemotherapy
    • Yes No
    • Excessive Thirst
    • Yes No
    • Swelling of Limbs
    • Yes No
  • Cordiovascular System
    • Artificial Heart Valve
    • Yes No
    • High Blood Pressure
    • Yes No
    • Tachycardia
    • Yes No
    • Chest Pain or Angina
    • Yes No
    • Low Blood Pressure
    • Yes No
    • Congenital Heart Defect
    • Yes No
    • Heart Attack
    • Yes No
    • Mitral Valve Prolapse
    • Yes No
    • Congestive Heart Failure
    • Yes No
    • Heart Murmur
    • Yes No
    • Pacemaker
    • Yes No
    • High Cholesterol
    • Yes No
  • Endocrine
    • Diabetes
    • Yes No
    • Thyroid Problems
    • Yes No
    • Hormonal Change
    • Yes No
    • Hypoglycemia
    • Yes No
  • Eyes, Ears, Nose, Throat
    • Change in Hearing
    • Yes No
    • Glaucoma
    • Yes No
    • Sinus Problems
    • Yes No
    • Change in Vision
    • Yes No
    • Hay Fever
    • Yes No
    • Tonsillectomy
    • Yes No
    • Difficulty Swallowing
    • Yes No
    • Nasal Obstruction
    • Yes No
    • Ringing in Ears(Tinnitis)
    • Yes No
    • Ear Pain
    • Yes No
    • Nose Bleeding
    • Yes No
  • Gastrointestinal
    • Acid Reflux
    • Yes No
    • Stomach/Intestinal Disease
    • Yes No
    • GERD
    • Yes No
    • Frequent Diarrhea
    • Yes No
    • Soft of Special Diet
    • Yes No
    • Ulcers
    • Yes No

  • Comments


  • Genitourinary
    • Frequent Urination
    • Yes No
    • Renal Dialysis
    • Yes No
    • Kidney Problems
    • Yes No
    • Venereal Disease
    • Yes No
    • Nocturia(Bed)
    • Yes No
    • Genital Herpes
    • Yes No
  • Hematological
    • Bleeding Problems
    • Yes No
    • Anemia
    • Yes No
    • Hepatitis
    • Yes No
    • Leukemia
    • Yes No
    • Blood Disease
    • Yes No
    • Blood Transfusion
    • Yes No
    • Hemophilia
    • Yes No
    • Bruise Easily
    • Yes No
  • Musculoskeletal
    • Back Pain
    • Yes No
    • Osteoporosis
    • Yes No
    • Fibromyalgia
    • Yes No
    • Spina Bifida
    • Yes No
    • Arthritis/Gout
    • Yes No
    • Muscle Weakness
    • Yes No
    • Rheumatism
    • Yes No
  • Neurological
    • Alzheimer's Disease
    • Yes No
    • Epilepsy or Seizures
    • Yes No
    • Tremor
    • Yes No
    • Dizziness/Fainting
    • Yes No
    • Stroke
    • Yes No
    • Parkinson's Disease
    • Yes No
    • Memory Loss
    • Yes No
    • Tingling/Numbness
    • Yes No
    • Convulsions
    • Yes No
    • Multiple Sderosis
    • Yes No
    • Trigeminal Neuralgia
    • Yes No
  • Oral
    • Bleeding Gums
    • Yes No
    • Jaw Joint Pain
    • Yes No
    • Teeth denching/grinding
    • Yes No
    • Canker Sores
    • Yes No
    • Dry Mouth
    • Yes No
    • Difficulty Chewing
    • Yes No
    • Tooth Pain
    • Yes No
    • Cold Sores/Fever Blisters
    • Yes No
    • Jaw Joint Problems
    • Yes No
    • Difficulty Chewing
    • Yes No
    • Orthodontics / Invisalign
    • Yes No
    • Wisdom Teeth Extraction
    • Yes No
    • Jaw Joint Clicking
    • Yes No
    • Periodontal Disease
    • Yes No
    • Have Removable Teeth
    • Yes No
  • Psychiatric
    • ADD/ADHD
    • Yes No
    • Eating Disorders
    • Yes No
    • Anxiety
    • Yes No
    • Excessive Stress
    • Yes No
    • Chemical Dependency
    • Yes No
    • Memory Problems
    • Yes No
    • Depression
    • Yes No
    • Psychiatric Care
    • Yes No
  • Respiratory
    • Asthma
    • Yes No
    • Emphysema
    • Yes No
    • Lung Disease
    • Yes No
    • Bronchitis
    • Yes No
    • Easily Winded/Dyspnea
    • Yes No
    • Tuberculosis
    • Yes No
    • Breathing Problems
    • Yes No
    • Pneumonia
    • Yes No
    • Congestion
    • Yes No
    • Frequent Cough
    • Yes No
  • Sleep
    • Daytime Sleepiness
    • Yes No
    • Snoring
    • Yes No
    • Morning Headaches
    • Yes No
    • Obstructive Sleep Apnea
    • Yes No
    • Do you use a CPAP
    • Yes No
  • Have you ever had any serious illness not listed above?
  • Yes No
  • 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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