(248) 347-3700

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(248) 347-3700

Adult New Patient Form

Dentists in Novi, MI

Step 1 of 5

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Insurance Information

Primary Insurance
Do You Have Dental Insurance?*
- Yes
- No
Name of Insured*
Employer*
Social Security #*
Name of Dental Insurance Co.*
Group #*
Address to send claims to
Insurance Card Copy Upload
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 32 MB.
Secondary Insurance
Do You Have Secondary Dental Insurance?*
- Yes
- No
Name of Insured*
Employer*
Social Security #*
Name of Dental Insurance Co.*
Group #*
Address to send claims to
Insurance Card Copy Upload
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 32 MB.

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Dental History
Name of Previous Dentist*
Date of last dental visit?*
- 0-6 Months
- 6-12 Months
- 12-24 Months
- greater than 24 months
Date of last x-rays?*
- 0-6 Months
- 6-12 Months
- 12-24 Months
- greater than 24 months
How often do you floss?*
How often do you brush?*
Do Any Apply To You?
Tooth Pain*
- Yes
- No
Broken Fillings*
- Yes
- No
Sensitivity to Sweets*
- Yes
- No
Finger or Nail Biting*
- Yes
- No
Periodontal Treatment*
- Yes
- No
Frequent Headaches*
- Yes
- No
Bad Breath*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Dental Anxiety*
- Yes
- No
Grinding Teeth*
- Yes
- No
Sensitivity to Cold*
- Yes
- No
Sensitivity to Heat*
- Yes
- No
Swelling/Lumps in Mouth*
- Yes
- No
Loose Teeth*
- Yes
- No
Missing Teeth*
- Yes
- No
Extraction Complications*
- Yes
- No
Removable Partial/Denture*
- Yes
- No
Food in Teeth*
- Yes
- No

Health History
Name of Physician
Date of last physical exam?*
- 0-6 Months
- 6-12 Months
- 12-24 Months
- greater than 24 months
Height
Weight
Do you smoke or use tobacco?*
- Yes
- No
How long?
If female, please answer the following
Are you taking birth control pills?
- Yes
- No
Are you pregnant?
- Yes
- No
How many weeks?
Are you nursing?
- Yes
- No
Allergies to medications

Are you allergic to any of the following
Aspirin*
- Yes
- No
Codeine*
- Yes
- No
Dental Anesthetics*
- Yes
- No
Erythromycin*
- Yes
- No
Jewelry*
- Yes
- No
Latex*
- Yes
- No
Metals*
- Yes
- No
Penicillin*
- Yes
- No
Tetracycline*
- Yes
- No
Other*
- Yes
- No
Other allergies
Check if you have, or have had symptoms in the following areas to a significant degree
Abnormal Bleeding*
- Yes
- No
Acid Reflux*
- Yes
- No
ADHD/ADD*
- Yes
- No
Alcohol Abuse*
- Yes
- No
Allergies*
- Yes
- No
Anemia*
- Yes
- No
Angina Pectoris*
- Yes
- No
Arthritis*
- Yes
- No
Artificial Heart*
- Yes
- No
Artificial Joints*
- Yes
- No
Asthma*
- Yes
- No
Blood Transfusions*
- Yes
- No
Cancer*
- Yes
- No
Chemotherapy/Radiation*
- Yes
- No
Colitis*
- Yes
- No
Congenital Heart Defect*
- Yes
- No
Cosmetic Surgery*
- Yes
- No
Diabetes*
- Yes
- No
Difficulty Breathing*
- Yes
- No
Drug Abuse*
- Yes
- No
Emphysema/COPD*
- Yes
- No
Epilepsy/Seizures*
- Yes
- No
Fainting Spells*
- Yes
- No
Fever Blisters*
- Yes
- No
Glaucoma*
- Yes
- No
Head/Neck Surgery*
- Yes
- No
Heart Attack*
- Yes
- No
Heart Surgery*
- Yes
- No
Hemophilia*
- Yes
- No
Hepatitis A, B, C*
- Yes
- No
High Blood Pressure*
- Yes
- No
Infective Endocarditis*
- Yes
- No
HIV/AIDS*
- Yes
- No
Kidney Problems*
- Yes
- No
Liver Disease*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Osteoporosis/Osteopenia*
- Yes
- No
Pace Maker*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Psychiatric Problems*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Shingles*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Sinus Problems*
- Yes
- No
STD, STI, HPV*
- Yes
- No
Stroke*
- Yes
- No
Thyroid Problems*
- Yes
- No
Tuberculosis*
- Yes
- No
Ulcers*
- Yes
- No
Yellow Jaundice*
- Yes
- No
Other*
- Yes
- No
Other Conditions
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.
List all medications, supplements, and/or vitamins taken within the last two years.

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENTS & BILLING INFORMATION VIA*
- Cell Phone Confirmation
- Home Phone Confirmation
- Work Phone Confirmation
- Text Message to my Cell Phone
- Email Confirmation
- Any of the Above
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA*
- Cell Phone Confirmation
- Home Phone Confirmation
- Work Phone Confirmation
- Text Message to my Cell Phone
- Email Confirmation
- Any of the Above
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the information provided.
Patient's Full Name*
Date*
MM slash DD slash YYYY
Patient Signature*
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

About Our Practice

We designed our waiting room to be both welcoming and comfortable. Yet, it is only an indication of the high quality dental care you’ll receive as one of our patients. Learn more about our Novi dental office. →

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Family Dentistry
Cosmetic Dentistry
Teeth Whitening
Veneers

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R. Peter Maly, DDS

43025 W. 10 Mile Rd.
Novi, MI 48375

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