Click on Calendar, select the year & month then click on date.
Call Us Now (248) 651-6810
1202 Walton Blvd., Suite 208 Rochester Hills, 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 :
*Your birthday :
Age : Sex : Male Female
*Home Address
City :
State :
Zip :
Apt# :
Marital status : Married Single Child Other :
*Home phone : () - -
Work :  ()- - -
*Email Address:
Preferred Appointment : Times - Morning Afternoon Evening Any Time
Days - Monday Tuesday Wednesday Thursday
Friday Saturday
Best time to call :
Whom may we thank for referring you to our practice? Another patient, friend Dental Office
Another patient, relative Work
Newspaper School
Yellow pages Other
If Other Please Mention :
Name of person or office referring you to our practice:
Spouse or Responsible Party Information
The following is for : the patient's spouse the person responsible for payment
Person Name :
Last Name : Middle Name : First Name :
Birthday :
Sex : Male Female
Marital status : Married Single Child Other :
Home phone : () - -
Work :  ()- - -
Best time to call :
Address City :
State : Zip :
Apt# :
Employment Information
The following is for : the patient the person responsible for payment
Employer Name :
Occupation :
Address City :
State : Zip :
Insurance Information
Primary Insurance
ls insured a patient? Yes No
Name of Insured :
Last Name : Middle Name : First Name :
Birthday :
ID Number : Group# :
Address City :
State : Zip :
Insured's Employer :
Address City :
State : Zip :
Patient's Relationship to Insured: Self Spouse Child Other :
Insurance Plan Name & Address :
Secondary Insurance
ls insured a patient? Yes No
Name of Insured :
Last Name : Middle Name : First Name :
Birthday :
ID Number : Group# :
Address City :
State : Zip :
Insured's Employer :
Address City :
State : Zip :
Patient's Relationship to Insured: Self Spouse Child Other :
Insurance Plan Name & Address :

Health Information

Date of last dental visit :
Reason for this visit :
Have you ever had any of the following? Please check those that apply :
AIDS
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease
Codeine Allergy
Penicillin Allergy
Pregnancy     Due date :
Allergies :
Current medications :
Have you ever had any complications following dental treatment? Yes   No
If yes,please explain:
Have you been admitted to a hospital or needed emergency care during the past two years? Yes   No
If yes,please explain:
Are you now under the care of a physician? Yes   No
If yes,please explain:
Name of physician :
Phone # : () --
Do you have any health problems that need further clarification? Yes   No
If yes,please explain:
* 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.

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.


All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.


Patients who carry dental insurance understand that all dental services performed are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients' insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charge will be paid by an insurance company.

A service charge of 11/2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.


I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.


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 as 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 be instituted hereunder.


I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
* I have read the above conditions of treatment and payment and agree to their content.

Radiograph and Records Request

** Please download and fill out this form only to request records from a previous dental office and
mail or fax it to that office.
Click to Download: Radiograph and Records Request


*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."
READ MORE

New Patient Registration

CLICK HERE
Dr. Aurelia has been voted by his Peers to be included in the 2014 DatAbase of Dentists in Rochester Hills - Top Dentist Logo
Dentists in Rochester Hills - Dawson Acedamy
Dentists in Rochester Hills - Acedamy of General Dentistry
Dentists in Rochester Hills - Spear