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989.389.4931
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New Patients

Registration

Please fill out and print the forms below.

St.Helen Family Dentistry
631 N. St. Helen RD., P.O. Box 9
St.Helen, MI 48656
989-389-4931

Patient Information

Name Birth Date
Soc. Security # DL#
Primary Phone (Home/Work/Cell) Secondary Phone (Home/Work/Cell)
Home Address City Zip
Employer Employer Address
Marital Status Name of Spouse/Parent/Guardian
Spouse/Guardian's Employer Spouse's Date of Birth
Person Responsible for Account Social Security #
Email Address
Physician's Name
Address Phone

Patient Dental History

  1. What is the main reason for your visit?
  2. Have you ever had problems . compications with dental treatment?
  3. Name and location of previous dentist:
  4. Date of last dental appointment and sest of full x-rays:
  5. How did you hear of our office?
  6. If someone referred you, please let us know so that we may thank them:

Insurance Information

Primary Dental Insurance Co.
Cardholder's Name
Cardholder's Date of Birth Cardholder's SS#
Mailing Address of Cardholder
Secondary Dental Insurance Co.
Cardholder's Name
Cardholder's Date of Birth Cardholder's SS#
Mailing Address of Cardholder

Consent

I, the undersigned, consent to treatment which is advisable and agreeable to both myself and the dentist with the realization that certain are and infrequent complications may occur. These may include injury to the following:

  1. Injury to adjacent restorations, teeth or other tissue.
  2. Trismus: prolonged muscle stiffness
  3. Fistula: small opening between the mouth and sinus following removal of upper teeth.
  4. Fracture of bone.
  5. Parathesia: nerve involvement that may result in numbness of lip, chin, gums or tongue.

I understand there can be no guarantees as to any treatment result or cure. I realize that additional Therapeutic procedures may become apparent during treatment and allow the dentist to use his judgment.




Signature of patient / guardian: ____________________________________________ Date: ____________________________________




Please give receptionist your insurance card and driver's license for copying