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804 N. Main Street #201A, Rochester, MI 48307 | Directions
Dentists in Rochester Hills - Young Couple

Patient Information

Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.
*Patient Name :
*Last Name :
Middle Name : *First Name :
*Birth Date:
Age : Sex : Male Female
*Home Address
City :
State :
Zip :
Apt# :
Marital status : Married Single Child Other :
*Cell phone #: () - -
Home or Secondary Phone #: ()- - -
*Email Address:

Health Information

Date of last dental visit :
Reason for this visit :
Have you ever had any of the following? Please check all that apply:
AIDS/HIV
Anemia
Arthritis
Asthma
Blood Disease
Chemotherapy
Diabetes
Dizziness
Epilepsy
Fainting
Glaucoma
Hay Fever
Head Injury
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorder
Nervous Disorder
Pacemaker
Current Pregnancy
Radiation Tx
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease
Allergies: Drug List
Allergies: Other List
Artificial Joints: Date
Cancer: Type
Heart Attack: Date
Thyroid: Hypo Hyper
Other: List
Please list current medications :
Please explain any health issues that need further clarification:
Please explain any complications the patient has had following dental treatment:
Has the patient been admitted to the hospital or needed emergency care during the past two years? If so, please explain:
Is the patient now under the care of a physician? If yes, please explain:
Name of physician :
Phone # : () --
* To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Responsible Party Information

The following information is for the person responsible for the payment of services
Person Name :
Last Name : Middle Name : First Name :
Birth Date:
Sex : Male Female
Marital status : Married Single Child Other :
Address City :
State : Zip :
Apt# :
Cell phone #: () - -
Alternate Phone #: ()- - -

Dental Insurance Information

Please note that this insurance may be different than your medical insurance carrier
Primary Insurance
Name of Subscriber:
Last Name : Middle Name : First Name :
Birth Date:
Employer Name:
Insurance Carrier Name:
Insurance Carrier Provider Phone#: ()- - -
Policy ID# (or SSN): Group# :
Claims Mailing Address: City :
State : Zip :
Patient’s relationship to Insured Subscriber:
Self Spouse Child Other :
Secondary Insurance
Name of Subscriber:
Last Name : Middle Name : First Name :
Birth Date:
Employer Name:
Insurance Carrier Name:
Insurance Carrier Provider Phone#: ()- - -
Policy ID# (or SSN): Group# :
Claims Mailing Address: City :
State : Zip :
Patient’s relationship to Insured Subscriber:
Self Spouse Child Other :

Referral Information

Whom may we thank for referring you to our practice? Another patient, friend Dental Office
Another patient, relative Work
Online search School
Other
If Other Please List :
Name of person or office referring you to our practice:

Consent for Services

As a condition of treatment by this office, patients are expected to pay their balance at the time of service, or to make financial arrangements in advance. The practice depends upon the reimbursement from patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment.


As a courtesy, for those patients who carry dental insurance, the practice will send claims to the patient's insurance company first. We will then send a statement for any remaining balance to the responsible party. This office cannot render services on the assumption that our charge will be paid by an insurance company. We ask that all patients update us immediately with any changes to insurance coverage.


A late fee or service charge of 1.5% per month (18% annum) on the unpaid balance, or $10.00 minimum per month may be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.


In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit shall be instituted hereunder.
* I have read the above conditions of treatment and payment and agree to their content.
* I grant my permission to you or your assignee to telephone me at home, or by mobile phone, or at my work to discuss matters related to this form.
* I grant my permission to you or your assignee to communicate with me electronically at the email address provided. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address. I can withdraw my consent to electronic communications at any time by calling 248-651-6810.
* I have read this practice's Financial Policy and agree to its terms and conditions.
* I have read this practice's Notice of Privacy Practices and agree to its terms and conditions.


Radiograph and Records Request

** Please complete this form only to request records from a previous dental office.
Dear Doctor,
Please accept this document as my formal request to have my most recent radiograph and dental records forwarded to the practice of Dr. John L. Aurelia and Dr. Dina Khoury at the following location:
John L. Aurelia, D.D.S., PLLC,
804 North Main Street, Suite 201-A,
Rochester, Michigan 48307
Email:frontdesk@aureliadds.com
Thank you for your assistance in this matter.
Previous Dentist’s Name:
Phone #: ()- -
Fax #: ()- -


*Signature of patient, parent or guardian
Relationship to Patient
*Signature of guarantor of payment/responsible party
Relationship to Patient
Date

Patient Review

Rating: 5Dentist Rochester Hills - 5 Star Rating
Dr. John Aurelia Reviewed byJeanette Jacobs

" Dr Aurelia and his staff are very professional and deliver a high level of care. Questions are always answered with understanding and kindness. I am so pleased with the care delivered by Dr Aurelia and his staff."
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Dr. Aurelia has been voted by his Peers to be included in the 2014 DatAbase of Dentists in Rochester Hills - Top Dentist Logo
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