Canton Office - (734) 844-1300 | South Lyon Office - (248) 437-1010

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I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Lifetime Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date below.

Do your gums bleed when you brush or floss?

Teeth sensitive to cold, hot, sweets, or pressure?

Is your mouth dry?

Any periodontal (gum) treatment?

Any orthodontic (braces) treatment?

Any problems from previous dental treatment?

Is your home water supply fluoridated?

Do you drink bottled or filtered water?

If yes, how often?

Experiencing dental pain or discomfort?

Any earaches or neck pain?

Do you brux or grind your teeth?

Any clicking, popping, or discomfort in the jaw?

Any sores or ulcers in your mouth?

Do you wear dentures or partials?

Are you active in recreational activities?

Any past injury to your head or mouth?

Experiencing any dental pain or discomfort?

Do you see any other physician or specialist?

AIDS/HIV

Anemia

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints

Asthma

Bleeding abnormally, with extractions or surgery

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Congenital Heart Lesions

Cortisone Treatments

Cough; persistent or bloody

Diabetes

Emphysema

Epilepsy

Fainting or dizziness

Glaucoma

Headaches

Heart Murmur

Heart Problems

Hepatitis

What Type of Hepatitis do you have

Herpes

High Blood Pressure

Jaundice

Jaw Pain

Kidney Disease

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Pacemaker

Psychiatric Care

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Sinus Trouble

Skin Rash

Special Diet

Stroke

Swollen Feet or Ankles

Swollen Neck Glands

Thyroid Problems

Tonsillitis

Tuberculosis

Tumor or growth on head or neck

Are you Pregnant?

Taking birth control pills?

Are you nursing?

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