Thank you for choosing our office. We strive to provide you with the most gentle, quality care possible.
If you have any questions, or we can help you in any way, please feel free to ask.

Patient Information (Confidential):

  • First Name
  • Last Name
  • (If child, parent/guardian name)
  • Birth date
  • Sex
  • Male Female
  • Age
  • Soc. Sec. #
  • Home Address
  • City
  • State
  • Zip
  • Home Phone
  • Work Phone
  • Cell Phone
  • Driver's License #
  • Email
  • Employer
  • Occupation
  • How long there?
  • May we call?
  • Employer Address
  • City
  • State
  • Zip
  • Spouse's Name (Or other parent/guardian)
  • Soc. Sec. #
  • Spouse's Employer
  • Occupation
  • How long there?
  • May We Call?
  • Spouse's Employer Address
  • City
  • State
  • Zip
  • If patient is a student: Name of School or College
  • City/State
  • Full or Part Time?
  • How did you hear about our practice?
  • Primary Insurance:

  • Name of Insured
  • Birth date
  • Relationship to patient
  • Address (if different from patient)
  • Dental Insurace Co.
  • Phone
  • Soc. Sec. #
  • Subscriber ID #
  • Group, Contract or Local or Union #
  • Additional Insurance:

  • Name of Insured
  • Birth date
  • Relationship to patient
  • Address (if different from patient)
  • Dental Insurace Co.
  • Phone
  • Soc. Sec. #
  • Subscriber ID #
  • Group, Contract or Local or Union #
  • Copayments:

  • To accept insurance, we now debit copayments automatically to your credit card. If you would like us to accept your Insurance, please provide credit card information:
  • Credit Card Debit Card
  • Master Card Visa American Express
  • Name of Card
  • Account #
  • Expiration Date
  • In case of emergency:

  • Name and City of primary care physician
  • Someone we may contact, not living with you
  • Phone #'s (home, work, cell)
  • Authorization:

  • I authorize my insurance company to make payments directly to the dental office for benefits otherwise payable to me. I authorize release of my records to third party payers, other healthcare professionals or operations, or other entities as deemed necessary by this office. I authorize use of this signature for all insurance submissions.
  • I understand that I am responsible for all charges whether or not they are covered by insurance, as well as any additional collection costs if this office determines they are necessary. I authorize this office to charge my credit card for any unpaid balances, including those after insurance payment. I understand that in certain circumstances, my credit report may be requested. I have reviewed the information on this form, and it is accurate to the best of my knowledge.
  • I have received a copy of this office's Notice of Privacy Practices.
  • Signature
  • Date
  • Patient or Responsible Party

Dental History

  • Patient Name
  • Age
  • Date
  • Reason for seeking care today:
  • Exam
  • Cleaning
  • Specific Problem
  • Please check all that apply:
  • Toothache
    Broken filling or tooth
    Sensitivity to:
    Food catches
    Loose teeth
    Floss breaks easily or hurts
  • Bite or teeth have shifted
    Often bite cheeks
    Frequent dry mouth
    Concerned about breath
    Unhappy with previous dental work
    Gums bleed
    Gums tender
    Growths, sores
    Cold sores, fever blisters
  • Cracked, chapped lips
    Bad taste in mouth
    Sinus problems
    Mouth breathe - Difficulty breathing through nose
    Dry or strained eyes
    Shoulder, neck or headaches
    Clench or grind teeth
    Jaw joint pain
    Clicking or popping of joint
  • Unable to open mouth wide
    Jaw gets tired easily
    Hold things between teeth (Pipe, pencil, nails, pins)
    Bite fingernails
    Unusual habits with teeth
    Wore braces
    Previous gum treatment
    Previous bite treatment
  • Would you like whiter teeth?
  • On a scale from 1 to 10, how would you rate your smile (with ten your smile is perfect.)
  • Please rate 1-10 how anxious you are about dental treatment (1 = totally relaxed)
  • Have you ever had a bad experience at the dentist? (Treatment? Staff? Billing?)
  • Why did you leave your previous dentist?
  • Did your parents have difficulties with their teeth or dental treatments?

Medical History

  • Physician's Name
  • City
  • Phone
  • Have you been hospitalized for any reason? Please describe:
  • Are you taking any medications or drugs (including nutritional supplements?) Please list: (Continue on back of form if needed)
  • Are you allergic to penicillin, aspirin, local anesthetics, latex, sulfa, codeine, other?
  • Do you smoke? How much/day? (Yes) / (No)
  • Pregnant? Due date
  • Are you nursing?
  • Are you seeing a physician now or planning to see one for any reason? Please explain:
  • Please check all that apply:
  • Previous injury to head or neck Diabetes Sickle cell Shortness of breath
    Heart problem HIV or AIDS Digestive problem, ulcer Snoring, sleep apnea
    Heart Attack Glaucoma Thyroid disease Seizures/Epilepsy
    Angina, chest pain Liver problem, jaundice Easily winded Fainting or dizzy
    Heart murmur Cirrhosis, Hepatitis Bleed or bruise easily Unexplained weight loss
    Scarlet, Rheumatic fever Cancer Stroke Chewing tobacco
    Mitral valve prolapse Radiation, Chemotherapy Parkinson's Drug or alcohol addiction
    Irregular heartbeat Respiratory problem Alzheimer's 2 or more social drinks/day
    High or low blood pressure Bloody, persistent cough Back problem Anxiety or nervous disorder
    Pacemaker Asthma, Emphysema Hives, rash, Herpes Insomnia
    Artificial joint Tuberculosis Prolonged bleeding Received any donor organs
    Arthritis Anemia Kidney problem
  • Please list any other illnesses or medical condition not checked above:
  • Please indicate if you would prefer to speak privately with the dentist about a medical issue:
  • Yes No
  • I will inform this office of any changes in my health status. I understand that dental treatment and local anesthesia entail risks such as bleeding, infection, nerve damage, or fracture of teeth or bone. I certify that the above information is complete and accurate to the best of my knowledge.
  • Patient Signature (parent or guardian)
  • Date
  • Dentist's Signature
  • _____________________
  • Date
  • _____________________

Written Financial Policy

  • Thank you for choosing Grosse Pointe Signature Smiles. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable as possible for our patients by offering payment options.
  • Payment Options:
    -Cash, check or credit cards such as Visa and Mastercard
  • -Payment Plans from CareCredit
    • Allow you to pay overtime some plans have NO interest
      Convenient, low monthly payment plans
      No annual fees or pre-payment penalties

    -Discount to help you save: We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion for treatment plans of $2000 or more. (If you have insurance, we will still process your claim having the benefits go directly to you.)
  • Please Note:
  • Requited Deposit: For larger, more comprehensive treatment plans of $500 or more, a 10% deposit is required to to secure your initial treatment. For plans requiring multiple appointments alternative payment arrangements may be provided.
  • Missed Appointment: A fee of $75 is charge for patient to mess or cancel more than one time in a calendar year without 48-hour notice.
  • Overdue Accounts: A charge of 10% interest on the balance for past accounts of 30 days or more.
  • Returned Checks: A charge of $50 for returned checks.
  • Dental Insurance: We are happy to work with your carrier to maximize your benefit and process your insurance for payment and in doing so we request your estimated time payment be paid when servers are delivered. However, your contract is between your employer and your carrier and we have no control over their decisions. Occasionally benefits are limited and payments are delayed. You're responsible for all financial cost a treatment and if your carrier does not pay in full within 90 days of service we will bill you for the outstanding balance.
  • VIP Checkout: You don't have to wait after your appointment! If you leave a credit card on file to cover any additional fees that may come do once your insurance payment is received we will automatically credit or debit or credit card.
  • If you have any questions please do not hesitate to ask, we are here to help you get the dentistry you deserve.
  • Date
  • Patient Name (please print)
  • Patient, Parent or Guardian Signature


You may refuse to sign this acknowledgement but, in refusing we
will not be allowed to process your insurance claims.

  • Date:
  • The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for Grosse Pointe Signature Smiles. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTORS IN THE FUTURE.
  • Please print your name
  • Legal Representative
  • Description of Authority
  • Please sign your name
    (This includes step parents, grandparents and any care takers who can have access to this patient's record
  • Name:
  • Relationship:
  • Name:
  • Relationship:
  • Name:
  • Relationship:

  • Cell Phone Confirmation
  • Home Phone Confirmation
  • Work Phone Confirmation
  • Text Message to my Cell Phone
  • Email Confirmation
  • U. S. Mail / Postcard
  • Any of the above
  • Message on Cell Phone
    Message on Home Phone
    Message on Work Phone
    Email Message
    U. S. Mail / Postcard
    Any of the above
  • Phone Message
    Text Message
    U. S. Mail / Postcard
    Any of the above
    None of the above
  • Office Use Only
  • As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:
  • It was emergency treatment
  • ___________________
  • I could not communicate with the patient
  • ___________________
  • The patient refused to sign
  • ___________________
  • The patient was unable to sign because
  • ___________________
  • Other (please describe)
  • ___________________
  • _____________________________
  • Signature of Privacy Officer

dental dental
Please enter code above in the field below.