Patient Forms

REQUIRED NEW PATIENT FORMS

The following forms should be downloaded, filled out, and signed by all new patients.

• Registration Form
• Health History Form
• Consent Form
• Family Members and Friends Involved In Discussing Patient Care Form

OPTIONAL PATIENT FORMS

The following forms may be required, depending on your clinic or procedure. Please contact 734-763-6933 if you are unsure which forms are required.

• Authorization for Patient Records (Printable PDF)
• Authorization for Patient Records (Fillable PDF) 
  (Complete all required fields and submit it using the instructions provided on the form. Call the Patient Duplication line at (734) 764-6152 if you have any questions.)
• Pediatric Dentistry Standard Health Questionnaire
• Temporary Guardian consent form for minor patients

PATIENT INFORMATION AND PRIVACY

The following documents provide information relating to patient rights and the University's privacy policies. The documents do not require signature.

• Important Patient Information
• Language Assistance
• Notice of Privacy Practices
• Patient Rights Brochure